a client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain today the client came into the clinic complaining of he

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?

A. Amputation
B. Deep vein thrombosis
C. Internal bleeding
D. Kidney failure

Correct answer: B

Rationale:

2. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

A. The nurse assesses capillary refill of 2 seconds
B. The nurse cannot insert one finger between the cast and the skin
C. The nurse finds 2+ pulses distal from the cast
D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

3. What is accurate health promotion teaching to prevent ear infection or trauma? (Select all that apply)

A. Blow nose gently without blocking nostrils
B. Wear hearing protection when exposed to loud noise
C. Avoid using cotton-tipped applicators to clean the external ear
D. All of the above

Correct answer: D

Rationale: The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.