what is the role of the nurse in the care of a patient with a pressure ulcer

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What is the role of the nurse in the care of a patient with a pressure ulcer?

A. Clean the wound and apply a protective dressing
B. Assess the wound and reposition the patient frequently
C. Apply pressure to the ulcer and monitor for signs of healing
D. Provide pain relief and administer antibiotics as needed

Correct answer: B

Rationale: The correct answer is B: Assess the wound and reposition the patient frequently. When caring for a patient with a pressure ulcer, it is crucial for the nurse to assess the wound regularly to monitor its progress and prevent complications. Additionally, repositioning the patient frequently helps to relieve pressure on the affected area, prevent further damage, and promote healing. Choice A is incorrect because while cleaning the wound is important, applying a protective dressing is not the primary role of the nurse in managing a pressure ulcer. Choice C is incorrect as applying pressure to the ulcer is harmful, and monitoring for signs of healing should not involve applying pressure. Choice D is incorrect as providing pain relief and administering antibiotics may be necessary but are not the primary interventions for managing a pressure ulcer.

2. A nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?

A. Restrict the client's fluid intake.
B. Monitor the client's deep-tendon reflexes.
C. Place the client in the lithotomy position.
D. Encourage the client to ambulate frequently.

Correct answer: B

Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.

3. A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?

A. Encourage the client to bend at the waist
B. Maintain the client in a high-Fowler's position
C. Place a pillow between the client's legs
D. Avoid placing a pillow under the client's knees

Correct answer: C

Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.

4. What is the process for taking a telephone order from a provider?

A. Patient name, drug, dose, route, frequency
B. Read back for accuracy
C. Have a witness listen to the order
D. Write down the order and follow up

Correct answer: B

Rationale: The correct process for taking a telephone order from a provider involves reading back the information for accuracy. This step ensures that the order is correctly understood and reduces the risk of errors. While listing patient information (Choice A) is essential, it does not encompass the complete process of verifying the order. Having a witness listen to the order (Choice C) may not always be practical or necessary, as direct verification is more efficient. Writing down the order and following up (Choice D) is not as crucial as the immediate read-back process, which allows for real-time clarification and confirmation.

5. How should a healthcare professional assess a patient with chest pain?

A. Assess the severity of pain and monitor ECG
B. Administer nitroglycerin and provide oxygen
C. Administer aspirin and provide pain relief
D. Monitor for nausea and administer IV fluids

Correct answer: A

Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.