nurse is reviewing the medical records of a client who has a pressure ulcer which of the following findings should the nurse expect
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the professional expect?

Correct answer: A

Rationale: The correct answer is A: Albumin level of 3. A low albumin level indicates poor nutrition, which can contribute to the development of pressure ulcers. Choice B, Hemoglobin of 12, is within the normal range and is not directly associated with pressure ulcers. Choice C, Normal skin moisture, does not provide specific information related to pressure ulcers. Choice D, No signs of infection, while important, is not a direct finding associated with pressure ulcers.

2. A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?

Correct answer: B

Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.

3. A healthcare provider is assessing a client who has carpal tunnel syndrome. The provider should expect which of the following findings?

Correct answer: C

Rationale: Phalen's sign is often positive in clients with carpal tunnel syndrome due to nerve compression. Chvostek's sign (Choice A) is related to hypocalcemia, cool extremities (Choice B) are not typically associated with carpal tunnel syndrome, and decreased radial pulse (Choice D) is not a common finding in carpal tunnel syndrome.

4. The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process?

Correct answer: C

Rationale: The correct answer is C: 'Do you have a chronic disease?' Patients with chronic diseases are more susceptible to infections due to factors like general debilitation and nutritional impairment. Choices A, B, and D are incorrect because having children in the home, having a spouse, or religious beliefs do not directly impact susceptibility to infectious diseases.

5. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

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