ATI PN Fundamentals 2020 with NGN

Extract:

Question 1 of 5

When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:

A. He has lain in one position for such a long time that swelling has occurred.B. An infection is in progress at the wound site.C. There is probably a deeper injury than what appears on the surface.D. Vessels have dilated and allowed plasma to leak into the wound site.

Correct Answer: D

Rationale: Swelling from dilated vessels leaking plasma is part of the inflammatory response, not necessarily infection.

Question 2 of 5

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

A. A client is unable to afford the physical therapy that the provider recommends.B. A client reports being dissatisfied with the temperature of the meals provided.C. A client's visitor becomes dizzy and faints in the client's room.D. A client receives burns from a heating pad.E. A client becomes disoriented and falls out of bed.

Correct Answer: C,D,E

Rationale: C: Visitor injury requires reporting. D: Client injury from equipment is reportable. E: Fall incidents must be documented for safety.

Question 3 of 5

A nurse observes assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

A. Lowering the side rail on the side of the bed where they will stand to perform mouth care.B. Using an oral care sponge swab moistened with cool water to clean the client's mouth.C. Wearing clean gloves to perform mouth care for the client.D. Using two gloved fingers to open the client's mouth for cleaning.

Correct Answer: A

Rationale: Lowering the side rail risks the unconscious client falling; it should remain up for safety.

Question 4 of 5

What type of wound heals by delaying the suturing until the infection is resolved?

A. Remodeling phaseB. Primary intentionC. Tertiary intentionD. Secondary intention

Correct Answer: C

Rationale: Tertiary intention delays suturing until infection clears, allowing controlled closure.

Question 5 of 5

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss?

A. I am going to have to find someone who can take care of my leg at home.B. I stay awake at night because I keep thinking about my leg.C. I need to learn how to perform a dressing change on my leg.D. I know my family means well, but I don't want visitors seeing my leg right now.

Correct Answer: C

Rationale: Wanting to learn dressing changes shows acceptance and adaptation to the amputation.

ATI PN Fundamentals 2020 with NGN | Nurselytic

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