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. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?

Correct answer: D

Rationale:

3. Which of the following assessments is found in neurovascular compromise?

Correct answer: A

Rationale: Tingling is a common sign of neurovascular compromise.

4. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

5. What can the nurse NOT teach a client with acquired immunodeficiency syndrome (AIDS) to reduce the risk of infection?

Correct answer: A

Rationale:

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