what nursing interventions increase the risk the pressure injuries
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. What nursing interventions increase the risk the pressure injuries?

Correct answer: B

Rationale:

2. What is the priority nursing diagnosis for a client with immobility?

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

3. A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is the first to occur?

Correct answer: B

Rationale:

4. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?

Correct answer: D

Rationale:

5. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

Correct answer: B

Rationale:

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