a client has an open wound with creamy thick yellow drainage how would the nurse document this finding

ATI RN

Multi Dimensional Care | Exam | Rasmusson

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

A. Purulent
B. Serosanguinous
C. Sanguineous
D. Serous

Correct answer: A

Rationale:

2. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?

A. Observe client for changes in mental status
B. Use aseptic technique for wound care and emptying of drains
C. Keep the client's heels off the bed
D. Perform neurovascular assessments per protocol

Correct answer: D

Rationale:

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

A. Passive range of motion
B. Pillows for positioning
C. Active range of motion
D. Continuous passive motion

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.

4. The nurse is caring for 4 clients. What client should the nurse see first?

A. A client with multiple children visiting
B. A client with lupus asking for dinner
C. A client on Methotrexate with a fever
D. A client with chronic rheumatic pain

Correct answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.