how can a nurse prevent pressure ulcers in an immobile patient
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. How can a healthcare provider prevent pressure ulcers in an immobile patient?

Correct answer: B

Rationale: Providing the immobile patient with a special mattress is an effective way to prevent pressure ulcers. Special mattresses help distribute pressure evenly and reduce the risk of developing pressure ulcers by relieving pressure on sensitive areas. Turning the patient every 4 hours (Choice A) is a standard practice to prevent pressure ulcers but may not be as effective as using a special mattress. Elevating the patient's legs (Choice C) can help with circulation but may not directly prevent pressure ulcers. Limiting the patient's movement (Choice D) can lead to other complications and is not a recommended method for preventing pressure ulcers.

2. A patient with a history of asthma is admitted with shortness of breath. What is the nurse's priority intervention?

Correct answer: A

Rationale: The correct answer is to administer a bronchodilator as prescribed. This intervention is the priority for a patient with asthma experiencing shortness of breath as it helps relax the airways, making breathing easier. Encouraging the use of an incentive spirometer (Choice B) is beneficial for lung expansion but not the priority in this acute situation. Placing the patient in a high Fowler's position (Choice C) can also help with breathing but is not as immediate as administering a bronchodilator. While monitoring the patient's oxygen saturation closely (Choice D) is important, the immediate action to address the breathing difficulty is administering a bronchodilator.

3. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

4. A nurse is teaching a patient with hypertension about the DASH diet. What is the most important instruction to include?

Correct answer: C

Rationale: The correct answer is to encourage the patient to reduce sodium intake. The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes reducing sodium intake to help manage hypertension. While increasing fruits and vegetables (Choice A) is important in the DASH diet, reducing sodium intake is considered more crucial. Limiting saturated fats (Choice B) is beneficial but not as critical as reducing sodium. Avoiding caffeine (Choice D) is not a specific recommendation of the DASH diet for managing hypertension.

5. Which goal is most appropriate for a patient who has had a total hip replacement?

Correct answer: B

Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.

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