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. 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. 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. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.

4. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
C. The UAP carefully empties the indwelling catheter bag
D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.