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
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Nursing Elites

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?

Correct answer: A

Rationale:

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

Correct answer: D

Rationale:

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

Correct answer: A

Rationale:

4. What does CREST stand for?

Correct answer: D

Rationale:

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

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