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

ATI RN

Multi Dimensional Care | Exam | Rasmusson

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

A. Amount
B. Consistency
C. Heat
D. Odor

Correct answer: C

Rationale:

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

A. The nurse assesses capillary refill of 2 seconds
B. The nurse cannot insert one finger between the cast and the skin
C. The nurse finds 2+ pulses distal from the cast
D. The nurse does not observe any drainage

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 device would be best to use for a client who is immobile?

A. Standing assist device
B. A mechanical lift
C. Transfer board
D. Gait belt

Correct answer: B

Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.