the nurse is assessing a client who had a cast placed 4 hours ago what assessment finding is cause for concern
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

1. 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.

2. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

3. What is an example of proper body mechanics when lifting?

Correct answer: D

Rationale: Proper body mechanics include holding objects close to the body to prevent injury.

4. What complication of fractures is caused by increased pressure which can result in decreased circulation to the area?

Correct answer: B

Rationale: Acute compartment syndrome is the correct answer. It involves increased pressure within muscles, leading to decreased blood flow and tissue damage. Venous thromboembolism (Choice A) is a condition where a blood clot forms in a vein, usually in the leg. Fat embolism syndrome (Choice C) occurs when fat globules enter the bloodstream and block blood vessels. Hemorrhage (Choice D) refers to bleeding, which can occur with fractures but does not specifically involve increased pressure leading to decreased circulation as in acute compartment syndrome.

5. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

Correct answer: A

Rationale:

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