the nurse assesses a deep wound the area is covered by black and necrotic tissue what term would the nurse use when documenting this wound

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?

A. Tunnelling
B. Eschar
C. Blanching
D. Cellulitis

Correct answer: B

Rationale:

2. The nurse is providing medication for a client with osteomyelitis. What teaching should the nurse indicate in the education?

A. The most common adverse e effect for nonsteroidal anti-inflammatory drugs (NSAIDS)are liver failure and tinnitus
B. The main side effect of acetaminophen is gastrointestinal GI bleeding
C. You should not take more than 4000 mg of acetaminophen a day
D. Nonsteroidal anti-inflammatory drugs (NSAIDS) are very safe and are known to have no side effects

Correct answer: A

Rationale:

3. The following client come to the ophthalmology clinic. Which client needs to be seen first?

A. Client who had recent cataract surgery and has worsening vision
B. Client with an absent red reflex on ophthalmic examination
C. Client with an intraocular pressure of 24 mm Hg
D. Client with a tearing, reddened eye with exudate

Correct answer: A

Rationale: Worsening vision after cataract surgery requires immediate attention to prevent complications.

4. What device would be best to use for a client who is immobile?

A. Standing assist device
B. A mechanical lift
C. Transfer board
D. Gait belt

Correct answer: B

Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.