a man has been admitted to the hospital unit with a medical diagnosis of copd he is receiving supplemental oxygen at 2 lmin via nasal cannula which po
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A man has been admitted to the hospital unit with a medical diagnosis of COPD. He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing?

Correct answer: D

Rationale:

2. What is the priority nursing diagnosis for a client with 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.

3. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?

Correct answer: C

Rationale:

4. What is the priority nursing diagnosis for a client with metastatic bone disease?

Correct answer: C

Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.

5. What nursing intervention is best to improve communication with a hearing-impaired client?

Correct answer: A

Rationale: Speaking slowly and clearly while facing the client improves communication with hearing-impaired clients.

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A nurse assesses an area of skin over a bony prominence. What finding would be most concerning?

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