a nurse is caring for an immobile client what is the priority assessment of this client

ATI RN

Multi Dimensional Care | Final Exam

1. A nurse is caring for an immobile client. What is the priority assessment of this client?

A. Palpate for edema
B. Auscultate for bowel sounds
C. Inspect the skin for injury
D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

2. What occurs during stage three of bone healing?

A. Consolidation
B. Callus formation
C. Granulation formation
D. Hematoma formation

Correct answer: B

Rationale: During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.

3. What is a sign of inadequate perfusion?

A. Intact sensation
B. Pallor in toes
C. Bounding pulses
D. Pink fingers

Correct answer: B

Rationale:

4. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?

A. Administer pain medication
B. Use proper hand hygiene and strict infection control
C. Delegate all client personal care to specific unlicensed assistive personnel
D. Plate the client in contact precautions

Correct answer: B

Rationale:

5. What finding is often present in a client with osteoporosis?

A. Chronic pain
B. Dupuytren’s contracture
C. Inflammation
D. Kyphosis

Correct answer: D

Rationale: Kyphosis is a common finding in osteoporosis due to vertebral compression fractures. Chronic pain (Choice A) can occur in osteoporosis but is not a specific finding. Dupuytren’s contracture (Choice B) is a condition affecting hand fingers' connective tissue, not typically associated with osteoporosis. Inflammation (Choice C) is not a typical finding in osteoporosis but rather a characteristic of other conditions.