Multi Dimensional Care | Final Exam

Question 1 of 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.

Question 2 of 5

What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

A. The UAP puts shoes on the client B. The UAP removes floor rugs and loose objects from the path C. The UAP walks to the side and slightly in front of the client D. The UAP uses a transfer (gait) belt

Correct Answer: C

Rationale:
Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation.

Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

Question 3 of 5

The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

A. Two-point gait B. Three-point gait C. Four-point gait D. Unaffected gait

Correct Answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg.

Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

Question 4 of 5

The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

A. The nurse assesses capillary refill of 2 seconds B. The nurse cannot insert one finger between the cast and the skin C. The nurse finds 2+ pulses distal from the cast D. The nurse does not observe any drainage

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

The nurse is caring for 4 clients. Which of these clients will the nurse see first?

A. A client with rheumatoid arthritis and a scheduled pain medication B. A client being discharged in 2 hours and needs to be taught how to use crutches C. A client with sudden and increasing pain in a fractured arm D. A client with a fractured ankle who would like a glass of water

Correct Answer: C

Rationale: The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage.

Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.

Multi Dimensional Care | Final Exam - Nurselytic

Nurselytic

ATI RN

ATI RN