a client is post operative day 1 and reports a sudden increase in blood tinged liquid draining from his incision after feeling a popping sensation wha

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

A. Send the client back to surgery
B. Assess the wound for signs of dehiscence
C. Call the provider immediately
D. Prepare to culture the wound

Correct answer: B

Rationale:

2. What is the nurse's priority action for a client with compromised immunity?

A. Wash hands before entering the client's room
B. Take the client's vital signs every 4 hours
C. Determine whether it is temporary or permanent
D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

3. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

A. Position the client on one side with the head turned towards you
B. Handle dentures with care
C. Use gentle brushing and flossing techniques for clients with fragile mucosa
D. Have a suction apparatus ready at the bedside

Correct answer: A

Rationale:

4. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?

A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?

Correct answer: B

Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.