the nurse is assessing a client who had a cast placed 4 hours ago what assessment finding is cause for concern

ATI RN

Multi Dimensional Care | Final Exam

1. 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.

2. A client has AIDS. Which of these findings indicate possible infection?

A. Respirations; 22 breaths per minute
B. Client ambulates 20 feet
C. Purulent drainage
D. Oxygen saturation; 97% on room air

Correct answer: C

Rationale:

3. What may be a cause of conductive hearing loss?

A. Prolonged exposure to loud noises
B. Medications
C. Presbycusis
D. Otitis media

Correct answer: D

Rationale: Otitis media can cause conductive hearing loss by affecting the middle ear.

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

A. A few missed doses per month are acceptable
B. Only specific licensed drugs are effective
C. These drugs inhibit viral replication
D. These drugs eradicate the virus

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.

5. What is a priority intervention when caring for a client in Buck’s traction?

A. Adjust the size of the traction weights PRN as needed
B. Discontinue the traction once the client has pain relief
C. Ensure the traction weights rest on the floor
D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.