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. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.

3. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Correct answer: A

Rationale:

4. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?

Correct answer: A

Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

5. What is the likely reason that a client with acquired immunodeficiency syndrome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not?

Correct answer: A

Rationale:

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