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 is not a potential complication of RA?

Correct answer: A

Rationale:

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

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.

4. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

5. What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?

Correct answer: C

Rationale:

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