a client sustained a crushing injury to his right arm during a car accident he arrives to the emergency room complaining of numbness in his right hand

ATI RN

Multi Dimensional Care | Final Exam

1. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?

A. Assess the right radial pulse
B. Call the provider
C. Administer pain medication
D. Assess the right pedal pulse

Correct answer: A

Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.

2. What is a negative effect of immobility on the cardiovascular system?

A. Increased high density lipoprotein
B. Increased circulation
C. Increased pumping action of the heart
D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system as it can lead to blood clots.

3. What lifestyle habits positively affect skin integrity?

A. Regular exercise
B. Tattoos
C. Smoking
D. Tanning

Correct answer: A

Rationale:

4. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?

A. Stage 3
B. Stage 4
C. Stage 1
D. Stage 2

Correct answer: D

Rationale:

5. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

A. The UAP puts shoes on the client
B. The UAP removes floor rugs and loose objects from the path
C. The UAP walks to the side and slightly in front of the client
D. The UAP uses a transfer (gait) belt

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.