a client is immobile and requires mechanical ventilation with a tracheostomy she has a pressure injury on her coccyx measuring 5 cm by 3 cm the nurse
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

Correct answer: D

Rationale:

2. The client has been asked to perform weight-bearing exercises three times a week. The client admits to not doing the recommended exercises. What is the most appropriate response by the nurse?

Correct answer: B

Rationale: The most appropriate response by the nurse is to ask the client to elaborate on their experience with the exercises. By doing so, the nurse can gain insight into any barriers the client may be facing and work together to find solutions to improve adherence. Choice A is not appropriate as it doesn't address the client's situation. Choice C is not relevant and may induce fear in the client. Choice D is directive and does not promote open communication or understanding of the client's perspective.

3. What is the best goal for pain control in a client with RA?

Correct answer: D

Rationale:

4. The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?

Correct answer: A

Rationale: Placing the bed in the lowest possible position increases the risk of injury because it does not support proper body mechanics. When lifting a client, it is important to have the bed at a comfortable height to avoid strain. Using the legs when lifting (choice B) is correct as it reduces the strain on the back. Keeping feet apart to provide a wide base of support (choice C) helps with stability and balance. Facing the direction of the movement (choice D) is essential for maintaining proper alignment and reducing the risk of injury.

5. What health teaching would not help an older adult avoid a musculoskeletal injury?

Correct answer: A

Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.

Similar Questions

A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?
The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?
During a skin inspection at the outpatient clinic, the nurse notices patches of thick, red skin with silvery scales on the client's elbows and knees. What skin abnormality does the nurse suspect?
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Why is traction used?

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