the nurse has documented the following wound assessment shallow open reddened ulcer with no slough on the anterior region of the right heel what stage
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?

Correct answer: D

Rationale:

2. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

Correct answer: D

Rationale:

3. The client complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse?

Correct answer: C

Rationale:

4. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?

Correct answer: D

Rationale:

5. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

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