how should a nurse care for a patient with a stage 2 pressure ulcer
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. How should a healthcare professional care for a patient with a stage 2 pressure ulcer?

Correct answer: C

Rationale: Using a hydrocolloid dressing is the appropriate care for a stage 2 pressure ulcer because it provides a moist healing environment, promotes healing, and helps to prevent infection. Cleaning the area with normal saline (Choice A) is important but not the primary treatment for a stage 2 pressure ulcer. Applying antibiotic ointment (Choice B) may not be necessary unless there is a sign of infection. Changing the dressing daily (Choice D) may disrupt the healing process and is not recommended unless the dressing is soiled or compromised.

2. What is the priority nursing action for a patient with respiratory distress?

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

3. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer?

Correct answer: A

Rationale: The correct answer is A: Pregabalin. Pregabalin is a first-line medication for treating pain in clients with fibromyalgia. It works by decreasing the number of pain signals sent out by damaged nerves. Choice B, Lorazepam, is a benzodiazepine used for anxiety and not indicated for fibromyalgia pain. Choice C, Colchicine, is used to treat gout by reducing inflammation and not indicated for fibromyalgia. Choice D, Codeine, is an opioid analgesic that is not typically recommended for fibromyalgia due to concerns about tolerance and dependence.

4. What is the most appropriate method to assess a patient's level of consciousness?

Correct answer: A

Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.

5. A nurse is reviewing the medical record of a client who has a new prescription for spironolactone. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: A serum creatinine level of 3.0 mg/dL indicates impaired kidney function, which is a concern when prescribing spironolactone as it can further affect renal function. Elevated serum creatinine levels may suggest decreased renal clearance of spironolactone, leading to potential toxicity. Potassium, calcium, and magnesium levels are within normal ranges and not directly related to spironolactone therapy. Therefore, the nurse should report the elevated serum creatinine level to the provider for further evaluation and possible dosage adjustment.

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