what is the priority nursing intervention for a patient with a stage 3 pressure ulcer what is the priority nursing intervention for a patient with a stage 3 pressure ulcer
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.

2. According to operant conditioning theory, __________.

Correct answer: D

Rationale: According to operant conditioning theory, the frequency of a behavior can be increased by following it with a wide variety of reinforcers. In operant conditioning, behaviors are shaped through reinforcement, which can be positive (rewarding) or negative (removal of something unpleasant). By providing reinforcement following a behavior, the likelihood of that behavior occurring again in the future is increased. This supports the notion that the frequency of a behavior can be increased by using reinforcers in operant conditioning. Choices A, B, and C are incorrect because operant conditioning focuses on the relationship between behavior and its consequences through reinforcement (positive or negative) to increase the likelihood of the behavior recurring, rather than punishment, cultural influences, or the development of the id based on societal values.

3. Where will the nurse collect the most reliable source of pain assessment?

Correct answer: From the client

Rationale:

4. Which fibers distribute the electrical impulse to the ventricles, causing them to contract?

Correct answer: A

Rationale: The correct answer is Purkinje fibers. Purkinje fibers are specialized conducting fibers that distribute the electrical impulse to the ventricles, leading to their contraction. The SA node (sinoatrial node) is responsible for initiating the electrical impulse in the heart, the AV node (atrioventricular node) delays the impulse to allow for proper atrial contraction before ventricular contraction, and the Bundle of His transmits the impulse from the AV node to the ventricles. Therefore, choices B, C, and D are not the correct options for fibers directly distributing the impulse to the ventricles.

5. What is a severe allergic reaction that can cause difficulty breathing and shock?

Correct answer: A

Rationale: Anaphylaxis is the correct answer. It is a severe, potentially life-threatening allergic reaction that can lead to difficulty breathing, low blood pressure, and loss of consciousness. An asthma attack is a separate condition characterized by narrowed airways and difficulty breathing, but it is not necessarily related to an allergic reaction like anaphylaxis. Bronchospasm refers to the sudden constriction of muscles in the bronchi, leading to breathing difficulties, and is not specific to allergic reactions. Hypersensitivity is a general term for an exaggerated immune response to a substance, which may or may not manifest as severe allergic reactions like anaphylaxis.

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