a nurse assesses an area of skin over a bony prominence what finding would be most concerning

ATI RN

Multi Dimensional Care | Exam | Rasmusson

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

A. Redness
B. Non-blanching
C. Blanching
D. Warmth

Correct answer: A

Rationale:

2. A client has a new arm cast. What is incorrect teaching by the nurse?

A. Use a sling to alleviate fatigue
B. Elevate the arm above the heart to reduce swelling
C. Report ‘hot spots’ felt under the cast
D. Sudden increase in drainage is expected

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

3. What is a priority intervention when caring for a client in Buck’s traction?

A. Adjust the size of the traction weights PRN as needed
B. Discontinue the traction once the client has pain relief
C. Ensure the traction weights rest on the floor
D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.