a nurse is caring for an intubated and sedated geriatric client what intervention is most appropriate for reducing the risk for a friction and shear i
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

Correct answer: A

Rationale:

2. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.

3. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?

Correct answer: B

Rationale:

4. What complication of fractures is caused by increased pressure which can result in decreased circulation to the area?

Correct answer: B

Rationale: Acute compartment syndrome is the correct answer. It involves increased pressure within muscles, leading to decreased blood flow and tissue damage. Venous thromboembolism (Choice A) is a condition where a blood clot forms in a vein, usually in the leg. Fat embolism syndrome (Choice C) occurs when fat globules enter the bloodstream and block blood vessels. Hemorrhage (Choice D) refers to bleeding, which can occur with fractures but does not specifically involve increased pressure leading to decreased circulation as in acute compartment syndrome.

5. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

Correct answer: C

Rationale:

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