the nurse has the client move both crutches forward with weight on the unaffected leg and move the unaffected leg forward shifting weight onto the una
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

1. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

2. What medication class can decrease tissue in inflammation but delays bone healing?

Correct answer: D

Rationale:

3. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?

Correct answer: C

Rationale:

4. The client states, “the doctor says I am nearsighted. I do not get it.” What would be the best response by the nurse?

Correct answer: B

Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.

5. A nurse is caring for an immobile client. What is the priority assessment of this client?

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

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What client is a susceptible host most at risk for infection?
The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
Which among the following is NOT the cause of pressure ulcers?

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