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. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

3. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)

A. A client on birth control pills
B. A client who is immobile
C. A client on an anticoagulant
D. A client with dementia who has been wandering

Correct answer: a

Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.

4. The client states, “the doctor says I am nearsighted. I do not get it.” What would be the best response by the nurse?

A. I am sorry you did not understand. Would you like a different doctor?
B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
C. You will need to have glasses.
D. This means you won’t ever need glasses.

Correct answer: B

Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.