what is the primary purpose of turning and repositioning an immobile patient every 2 hours

ATI RN

ATI Capstone Comprehensive Assessment B

1. What is the primary purpose of turning and repositioning an immobile patient every 2 hours?

A. To improve circulation and relieve pressure.
B. To prevent contractures and muscle atrophy.
C. To prevent skin breakdown and pressure ulcers.
D. To improve respiratory function and prevent pneumonia.

Correct answer: C

Rationale: The primary purpose of turning and repositioning an immobile patient every 2 hours is to prevent skin breakdown and pressure ulcers. Prolonged immobility can lead to pressure ulcers, making this a crucial nursing intervention. Choice A is incorrect because while turning can help improve circulation and relieve pressure, the primary purpose is to prevent skin breakdown. Choice B is incorrect as preventing contractures and muscle atrophy is important but not the primary purpose of turning. Choice D is incorrect as improving respiratory function and preventing pneumonia are not directly related to turning and repositioning for skin integrity.

2. When is removal of the restraints by the nurse appropriate?

A. When medication that has been administered has taken effect
B. When no acts of aggression are observed in the hour following the release of two extremity restraints
C. When the nurse explores with the client the reasons for the angry and aggressive behavior
D. When the client apologizes and tells the nurse that it will never happen again

Correct answer: B

Rationale: The correct answer is B. The nurse can safely remove restraints once no aggressive behavior is observed after releasing two extremity restraints for an hour. Choice A is incorrect because the removal of restraints should be based on the client's behavior rather than just the effect of medication. Choice C is incorrect as exploring reasons for aggressive behavior should be done before or during the intervention, not as a condition for removing restraints. Choice D is incorrect since an apology from the client does not guarantee a change in behavior or indicate that it is safe to remove the restraints.

3. A nurse is preparing to administer a medication that requires a peak and trough level. What is the nurse's priority action?

A. Administer the medication before the peak level is obtained.
B. Withhold the medication until the trough level is obtained.
C. Administer the medication based on the previous trough level.
D. Ensure that the medication is administered within 2 hours of the peak level.

Correct answer: B

Rationale: The nurse's priority action should be to withhold the medication until the trough level is obtained. This is crucial to ensure accurate dosing based on the patient's levels. Administering the medication before the peak level is obtained (choice A) can lead to incorrect dosing. Administering the medication based on the previous trough level (choice C) may not reflect the current levels accurately. Ensuring that the medication is administered within 2 hours of the peak level (choice D) is not necessary for obtaining accurate peak and trough levels.

4. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?

A. Reevaluate the temperature and white blood cell count in 4 hours.
B. Check which solution was used for skin preparation in surgery.
C. Plan to change the surgical dressing during the shift.
D. Utilize SBAR to notify the primary health care provider.

Correct answer: D

Rationale: The patient is showing signs of a possible surgical site infection, including redness, purulent drainage, tenderness, elevated temperature, and increased white blood cell count. These symptoms suggest the need for immediate action to address a potential complication. Utilizing SBAR to notify the primary health care provider is crucial as it allows for effective communication of the patient's condition and the need for further assessment and intervention. Reevaluating the temperature and white blood cell count later, checking the solution used for skin preparation, or planning to change the dressing do not address the urgent need for intervention and communication with the healthcare provider.

5. The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?

A. Prepare for potential posttraumatic stress related to this bioterrorism attack.
B. Transport patients quickly and efficiently through the elevators.
C. Monitor for specific symptoms related to the bioterrorism attack.
D. Manage all patients using standard precautions.

Correct answer: D

Rationale: During a potential bioterrorism attack, the priority for the nurse is to manage all patients using standard precautions. This approach ensures the safety of both patients and healthcare providers by preventing the spread of potential bioterrorism-related illnesses. Option A is incorrect because managing patient care and safety through standard precautions takes precedence. Option B is incorrect as patient transport should also be done while adhering to infection control measures. Option C is incorrect as monitoring for specific symptoms is important but not the priority when all patients need to be managed with standard precautions.