the client is at risk for impaired skin integrity related to the need for several weeks of bedrest the nurse evaluates the client after 1 week and fin
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

Correct answer: D

Rationale:

2. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?

Correct answer: D

Rationale:

3. What should the nurse do first if they are stuck by a needle?

Correct answer: B

Rationale:

4. Where will the nurse collect the most reliable source of pain assessment?

Correct answer: C

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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