A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?

Questions 138

ATI RN

ATI RN Test Bank

ATI Capstone Fundamentals Assessment Proctored Questions

Question 1 of 5

A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?

Correct Answer: C

Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.

Question 2 of 5

A nurse is planning to administer multiple medications to a client with dysphagia. What action should the nurse take?

Correct Answer: C

Rationale: The correct action for the nurse to take when administering medications to a client with dysphagia is to place the medications in small amounts of pudding. Mixing medications with pudding helps clients with dysphagia swallow them more easily. Choice A (crushing medications and mixing with honey) is not recommended as it may alter the medication properties. Choice B (providing medications through a straw) is not suitable for clients with dysphagia as it can pose a choking hazard. Choice D (offering medications with a full glass of water) may be difficult for clients with dysphagia to swallow and increase the risk of aspiration.

Question 3 of 5

A client with an indwelling urinary catheter is being cared for by a nurse. What finding indicates a catheter occlusion?

Correct Answer: A

Rationale: Bladder distention is the correct answer as it indicates that the catheter is not draining properly, which is a sign of occlusion. Frequent urination, hematuria, and burning sensation are not indicative of a catheter occlusion. Frequent urination may suggest a bladder that is not fully emptying, hematuria indicates blood in the urine, and a burning sensation can be a sign of a urinary tract infection, none of which directly relate to a catheter occlusion.

Question 4 of 5

A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?

Correct Answer: B

Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.

Question 5 of 5

A nurse is caring for a client who is postop following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?

Correct Answer: B

Rationale: The correct answer is B: Decreased physical activity. Following abdominal surgery, reduced physical activity can contribute to constipation due to decreased bowel motility. Increased fiber intake (choice A) generally helps prevent constipation by adding bulk to the stool. Frequent urge suppression (choice C) may lead to issues like urinary retention but is not directly linked to constipation. Adequate sleep (choice D) is important for overall recovery but does not significantly impact constipation risk.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days

Similar Questions