the client states why am i getting protein supplements while i am healing from a bed sore what is the best response by the nurse
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?

Correct answer: B

Rationale:

2. A client has a new arm cast. What is incorrect teaching by the nurse?

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

3. What is the priority nursing diagnosis for a client with immobility?

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

4. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

Correct answer: A

Rationale:

5. A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?

Correct answer: C

Rationale: Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.

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