a nurse is providing oral hygiene for an unconscious client what is the priority nursing intervention
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

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

Correct answer: A

Rationale:

2. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

3. What is correct about a nursing diagnosis?

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.

4. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?

Correct answer: B

Rationale:

5. A client has a fractured right arm. What should the nurse do first?

Correct answer: C

Rationale: The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.

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