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. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?

A. Stage 3
B. Stage 4
C. Stage 1
D. Stage 2

Correct answer: D

Rationale:

3. To promote independence, which of these is the best intervention to implement?

A. Perform the clientâ€™s activities of daily living for them.
B. Speak directly in front of the client so they can read your lips well.
C. Give the client their washcloth and toothbrush and leave the room.
D. Allow the client to perform the activities of daily living they are able to do.

Correct answer: D

Rationale: The correct answer is to allow the client to perform the activities of daily living they are able to do. This intervention promotes independence by encouraging clients to maintain their functional abilities. Choice A is incorrect as performing the client's activities of daily living for them does not empower independence. Choice B is irrelevant to promoting independence. Choice C is not actively promoting independence as it involves leaving the client alone without any guidance or support.