a client is in skeletal traction with the nurses assessment it is noted that the pairs appear red swollen and there is purulent drainage what action d

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?

A. Collect a culture of the purulent fluid
B. Cleanse the skin around the pins
C. Administer an antibiotic
D. Instruct the client to complete exercise of the affected extremity

Correct answer: A

Rationale:

2. Which assessment is NOT a nonverbal sing of pain?

A. Decreased attention span
B. Grimacing
C. Increase in heart rate
D. Reported pain of 5/10

Correct answer: D

Rationale:

3. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

A. Position the client on one side with the head turned towards you
B. Handle dentures with care
C. Use gentle brushing and flossing techniques for clients with fragile mucosa
D. Have a suction apparatus ready at the bedside

Correct answer: A

Rationale:

4. What does CREST stand for?

A. Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly and Telecines
B. Calcinosis, Reverse isolation, Esophageal dysmotility, Sclerodactyly and Telangiectasia
C. Calcinosis, Raynaud's, Everted colon, Sclerodactyly and Telangiectasia
D. Calcinosis, Raynaud's Esophageal dysmotility, Sclerodactyly and telangiectasia

Correct answer: D

Rationale:

5. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.