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
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Nursing Elites

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?

Correct answer: B

Rationale:

2. 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?

Correct answer: D

Rationale:

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

Correct answer: A

Rationale:

4. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?

Correct answer: B

Rationale:

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

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.

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