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. What is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV)?

Correct answer: C

Rationale: The correct answer is that antiretroviral drugs inhibit viral replication. These medications work by interfering with the ability of the HIV virus to multiply in the body, helping to control the infection. Choice A is incorrect because consistency in taking antiretroviral drugs is crucial to their effectiveness. Missing doses can lead to treatment failure and the development of drug-resistant strains of HIV. Choice B is incorrect as there are multiple licensed drugs that are effective in treating HIV. Choice D is also incorrect as antiretroviral drugs do not kill the virus but rather suppress its replication.

3. A client has an open wound with creamy thick yellow drainage. How would the nurse document this finding?

Correct answer: A

Rationale:

4. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?

Correct answer: D

Rationale: Touching the dropper to the eye contaminates it and can lead to infection.

5. What is the best nursing intervention for a client with limited mobility who cannot move independently?

Correct answer: A

Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.

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