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. What is a negative effect of immobility on the cardiovascular system?

A. Increased high density lipoprotein
B. Increased circulation
C. Increased pumping action of the heart
D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system as it can lead to blood clots.

3. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?

A. Offer the client protein with meals to promote healing
B. Remove the old dressing with clean gloves
C. Teach the client about nonpharmacological pain control methods
D. Check medication administration record (MAR)for as needed orders (PRN)

Correct answer: C

Rationale:

4. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?

A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?

Correct answer: B

Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.