a client on bed rest complains of pain and burning in the right calf area what is the nurses action

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

A. Deeply palpate the area for rebound tenderness
B. Medicate the client for pain and reassess in 60 minutes
C. Percuss over the area for a change in tone
D. Compare the circumference to the left calf

Correct answer: D

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. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?

A. Stage 3
B. Stage 4
C. Stage 1
D. Stage 2

Correct answer: D

Rationale:

4. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

5. What is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV)?

A. A few missed doses per month are acceptable
B. Only specific licensed drugs are effective
C. These drugs inhibit viral replication
D. These drugs eradicate the virus

Correct answer: C

Rationale: The correct answer is that antiretroviral drugs inhibit viral replication. These medications work by interfering with the ability of the HIV virus to multiply in the body, helping to control the infection. Choice A is incorrect because consistency in taking antiretroviral drugs is crucial to their effectiveness. Missing doses can lead to treatment failure and the development of drug-resistant strains of HIV. Choice B is incorrect as there are multiple licensed drugs that are effective in treating HIV. Choice D is also incorrect as antiretroviral drugs do not kill the virus but rather suppress its replication.