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

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?

A. Diagnosis
B. Assessment
C. Implementation
D. Evaluation

Correct answer: B

Rationale:

2. A client has suffered from a femur fracture. What is the nurse's priority assessment?

A. Pain
B. Medication history
C. Pedal pulses
D. Socio-economic status

Correct answer: C

Rationale:

3. A well-rounded fitness program focuses on flexibility, resistance training and aerobic conditioning. What statements are true about a well-rounded fitness program? (Select all that apply)

A. Movement against resistance increases muscular strength and endurance
B. Intensity is the amount of time a person is exercising
C. Stretching after exercise cools the muscles and limits post exercise stiffness
D. all of the Above

Correct answer: D

Rationale: Resistance training, proper stretching, and exercise duration/intensity contribute to a well-rounded fitness program.

4. Why is traction used?

A. It allows the bones to realign
B. It decreases the risk of misalignment
C. It promotes wound healing
D. It allows the client to rest longer

Correct answer: A

Rationale: Traction is used to help align the bones properly during the healing process. Choice A is correct because traction assists in allowing the bones to realign correctly, promoting proper healing. Choice B is incorrect as traction does not decrease the risk of misalignment; instead, it helps reduce misalignment by aiding in bone alignment. Choice C is incorrect because while traction indirectly supports wound healing by ensuring proper bone alignment, its primary purpose is not wound healing. Choice D is incorrect as the primary purpose of traction is not to allow the client to rest longer, but rather to aid in bone alignment for optimal healing.

5. What is a priority intervention when caring for a client in Buck’s traction?

A. Adjust the size of the traction weights PRN as needed
B. Discontinue the traction once the client has pain relief
C. Ensure the traction weights rest on the floor
D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.