a nurse working in an orthopedic unit is caring for 4 clients which of the following clients should the nurse identify as being at highest risk for sk

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?

A. An adolescent who has a patella fracture and is in an immobilizer
B. A young adult who has a femur fracture and is going to surgery in two hours
C. A middle-aged adult who has fractured his radius and has a cast
D. An older adult who has a hip fracture and is immobile

Correct answer: D

Rationale:

2. Which client is at highest risk of compromised immunity?

A. A client who just had surgery
B. A client who just delivered a baby
C. A client with extreme anxiety
D. A client who is awaiting surgery

Correct answer: A

Rationale:

3. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

A. Send the client back to surgery
B. Assess the wound for signs of dehiscence
C. Call the provider immediately
D. Prepare to culture the wound

Correct answer: B

Rationale:

4. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?

A. 15 degrees
B. 0 degrees
C. 90 degrees
D. 30 degrees

Correct answer: C

Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.