a client has a fractured right arm which of these should the nurse complete first

ATI RN

Multi Dimensional Care | Final Exam

1. A client has a fractured right arm. What should the nurse do first?

A. Apply ice to the fracture site
B. Administer pain medications
C. Remove the client’s bracelet and rings from the right arm
D. Send the client to radiology for an x-ray

Correct answer: C

Rationale: The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.

2. A client is diagnosed with glaucoma. The provider needs to determine if it is open-angle glaucoma or closed-angle glaucoma. What test does the nurse anticipate?

A. Ultrasonic imaging
B. Gonioscopy
C. Corneal staining
D. Electroretinography

Correct answer: B

Rationale: Gonioscopy is the appropriate test to anticipate in this scenario. It is used to distinguish between open-angle and closed-angle glaucoma by examining the angle where the iris meets the cornea. Choice A, ultrasonic imaging, is not typically used to differentiate between these types of glaucoma. Choice C, corneal staining, is used to detect corneal abrasions and defects, not to differentiate between types of glaucoma. Choice D, electroretinography, is a test that measures the electrical responses of various cell types in the retina and is not specific to differentiating between open-angle and closed-angle glaucoma.

3. A client recently had an above the knee amputation and complains of pain distal to the amputation. What type of pain is the client experiencing?

A. Nociceptive
B. Neuropathic
C. Visceral
D. Cutaneous

Correct answer: A

Rationale:

4. Which finding is not typically associated with inflammation in a client?

A. Pain
B. Heat
C. Polyuria
D. Erythema

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.

5. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?

A. Encouraging bedrest
B. Applying antiembolism stockings
C. Tell the client to take anticoagulants
D. Teaching about smoking cessation

Correct answer: B

Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.