which of the following patients is at greatest risk for developing pressure ulcers
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2024

1. Which of the following patients is at greatest risk for developing pressure ulcers?

Correct answer: B

Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.

2. A healthcare professional is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the professional NOT include in the teaching?

Correct answer: B

Rationale: Weight gain is not a typical manifestation of tuberculosis. The characteristic symptoms of tuberculosis include a persistent cough, fatigue, and night sweats. Weight loss, not weight gain, is a common symptom associated with tuberculosis due to the impact of the infection on the body's metabolism. Therefore, the healthcare professional should exclude weight gain from the teaching on tuberculosis manifestations.

3. A client has experienced a right-hemispheric stroke. Which of the following is not an expected finding?

Correct answer: D

Rationale: In a right-hemispheric stroke, the expected findings include left-sided hemiplegia (Choice B), loss of depth perception (Choice C), and impulse control difficulty (Choice A). Aphasia (Choice D) is typically associated with left-hemispheric strokes. Therefore, aphasia is not an expected finding in a client who has experienced a right-hemispheric stroke.

4. All of the following interventions are correct when using the Z-track method of drug injection except:

Correct answer: D

Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1” long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.

5. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

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