a client is in skeletal traction with the nurses assessment it is noted that the pairs appear red swollen and there is purulent drainage what action d

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?

A. Collect a culture of the purulent fluid
B. Cleanse the skin around the pins
C. Administer an antibiotic
D. Instruct the client to complete exercise of the affected extremity

Correct answer: A

Rationale:

2. 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.

3. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?

A. I will drink at least 3000 mL of water daily."?
B. . 'I will shower every day in hot water."?
C. I will avoid tights belts."?
D. I will use a humidifier during the winter months."?

Correct answer: B

Rationale:

4. What device would be best to use for a client who is immobile?

A. Standing assist device
B. A mechanical lift
C. Transfer board
D. Gait belt

Correct answer: B

Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.