what are the nursing interventions for a patient with a pressure ulcer what are the nursing interventions for a patient with a pressure ulcer
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023

1. What are the nursing interventions for a patient with a pressure ulcer?

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

2. The client with chronic kidney disease (CKD) is receiving hemodialysis. Which finding should be reported to the healthcare provider immediately?

Correct answer: D

Rationale: A potassium level of 6.5 mEq/L is dangerously high, a condition known as hyperkalemia, which can lead to severe cardiac complications like arrhythmias and cardiac arrest. Immediate medical intervention is necessary to lower potassium levels to prevent life-threatening outcomes in clients undergoing hemodialysis.

3. Who is credited with creating a written record of health care practices and dispelling the mythical aspect of health care?

Correct answer: C

Rationale: Hippocrates is credited with creating the first medical textbook, where he documented contemporary health care practices and separated them from the mythical belief that Apollo was responsible for health. Hippocrates' work laid the foundation for evidence-based medicine and emphasized the importance of observation and clinical experience in healthcare practices. Choice A, Hammurabi, is known for his code of laws rather than medical advancements. Florence Nightingale is recognized for her contributions to nursing and healthcare reform, not for creating a written record of health care practices. Apollo, a Greek god associated with healing, is part of the mythical aspect of health care that Hippocrates aimed to dispel.

4. A client has a prescription for ranitidine 150 mg PO BID. Available is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day?

Correct answer: A

Rationale: To administer a total of 300 mg daily (150 mg PO BID), the nurse should give 20 mL of the syrup. This is calculated by dividing the total daily dose (300 mg) by the concentration of the syrup (15 mg/mL), which equals 20 mL. Choice B (15 mL), C (25 mL), and D (10 mL) are incorrect because they do not accurately calculate the required volume of syrup needed to deliver the prescribed dose.

5. A client is preparing advance directives. Which of the following statements by the client indicates an understanding of advance directives?

Correct answer: D

Rationale: The correct answer is D: 'I have the right to refuse treatment.' This statement indicates an understanding of advance directives because advance directives allow individuals to express their treatment preferences, including the right to refuse treatment if they choose to do so. Choice A is incorrect because individuals can update or change their advance directives as needed. Choice B is incorrect because advance directives are based on the individual's preferences, not the doctor's approval. Choice C is incorrect as witnessing an advance directive typically requires a witness who is not an attorney, depending on the state's specific requirements.

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