the nurse assesses a wound with exudate what should not be included when documenting the exudate
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?

Correct answer: C

Rationale:

2. What nursing interventions increase the risk the pressure injuries?

Correct answer: B

Rationale:

3. What soft tissue musculoskeletal injury is excessive stretching of a ligament?

Correct answer: A

Rationale: A sprain is an injury involving excessive stretching of a ligament.

4. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?

Correct answer: D

Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.

5. A client has a new arm cast. What is incorrect teaching by the nurse?

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

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