the nurse notices a new area of skin breakdown near the site of a dressing this would be an example of which phase of the nursing process
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?

Correct answer: B

Rationale:

2. What are signs of hearing loss? (Select all that apply)

Correct answer: C

Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.

3. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?

Correct answer: B

Rationale:

4. The nurse is caring for a 65-year-old client and notes a temperature of 101°F. How does the nurse interpret this finding?

Correct answer: A

Rationale: A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

5. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?

Correct answer: B

Rationale:

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