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
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Nursing Elites

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?

Correct answer: D

Rationale:

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

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?

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?

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.

5. Which assessment is NOT a nonverbal sing of pain?

Correct answer: D

Rationale:

Similar Questions

The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
A client with a diagnosis of Human Immunodeficiency Virus develops pneumonia. What type of infection is this?
The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?
Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?
Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

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