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. 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.

3. What repetitive stress injury is a factory worker at risk of?

A. Plantar fasciitis
B. Osteomalacia
C. Carpal tunnel syndrome
D. Osteoporosis

Correct answer: C

Rationale: Factory workers are at risk of developing Carpal Tunnel Syndrome due to repetitive hand movements involved in their work. This condition occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. Plantar fasciitis (choice A) is a condition affecting the foot, not typically associated with factory work. Osteomalacia (choice B) is a softening of the bones due to a lack of vitamin D or calcium, not directly related to repetitive stress in factory work. Osteoporosis (choice D) is a condition characterized by weak and brittle bones, usually associated with aging or hormonal changes rather than repetitive stress injuries.

4. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

A. The pain will go away after the swelling decreases.
B. That is phantom limb pain.
C. Your foot has been amputated, so you are not having pain in that foot.
D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.