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 is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

Correct answer: D

Rationale:

3. What statement by the client with plantar fasciitis indicates a need for further teaching?

Correct answer: A

Rationale: The correct answer is A. Using warm packs can exacerbate inflammation in plantar fasciitis. Choices B, C, and D are all appropriate interventions for managing plantar fasciitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation. Resting and stretching the feet can promote healing and reduce symptoms. Wearing supportive shoes can provide stability and reduce strain on the plantar fascia. Therefore, the client's statement about using warm packs indicates a need for further teaching as it can worsen the condition.

4. A nurse is caring for an immobile client. What is the priority assessment in this client?

Correct answer: A

Rationale:

5. The client with rheumatoid arthritis is having her rheumatoid factor (RF) drawn while she is having a flare-up of the disease. Which result is seen in clients with rheumatoid arthritis?

Correct answer: C

Rationale:

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