a wound has a blood tinged liquid that is dripping from the surgical site how does the nurse document this finding
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

Correct answer: C

Rationale:

2. A nurse is assessing a client with hallux valgus. What is another term for this assessment finding?

Correct answer: B

Rationale: Hallux valgus is commonly known as a bunion, which is a bony bump that forms on the joint at the base of the big toe. A) Thoracic deformity is unrelated to hallux valgus. C) A corn is a thickened area of skin on the foot, not synonymous with hallux valgus. D) Metacarpal involvement refers to the hand, not the foot where hallux valgus occurs.

3. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

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

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.

5. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

Correct answer: D

Rationale:

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