a client is immobile and requires mechanical ventilation with a tracheostomy she has a pressure injury on her coccyx measuring 5 cm by 3 cm the nurse

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

A. Stage III pressure injury
B. A stage II pressure injury
C. A non-staging pressure injury
D. Stage IV pressure injury

Correct answer: D

Rationale:

2. What is a negative effect of immobility on the cardiovascular system?

A. Increased high density lipoprotein
B. Increased circulation
C. Increased pumping action of the heart
D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system as it can lead to blood clots.

3. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?

A. Ischial tuberosity
B. Compartment syndrome
C. Broken arm syndrome
D. Pulmonary embolism

Correct answer: B

Rationale:

4. What is not a potential complication of RA?

A. Paresthesia's
B. Fibromyalgia
C. Joint deformity
D. Dry eyes

Correct answer: A

Rationale:

5. The nurse is caring for 4 clients. Which of these clients will the nurse see first?

A. A client with rheumatoid arthritis and a scheduled pain medication
B. A client being discharged in 2 hours and needs to be taught how to use crutches
C. A client with sudden and increasing pain in a fractured arm
D. A client with a fractured ankle who would like a glass of water

Correct answer: C

Rationale: The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage. Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.