ATI Mobility & Tissue Integrity Quiz

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?

Use a moisturizer to wipe urine from the skin.

A nurse is teaching a client who has a new prescription for topical betamethasone to treat contact dermatitis. Which of the following instructions should the nurse include?

"Use the cream for a few days after the area has healed."

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following should the nurse perform first?

Cover the wound with a moist, sterile gauze dressing.

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Increasing edema

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.

Place a waterproof pad under the client's leg, apply clean gloves to remove dressing, clean site using circular motion, open sterile kit, irrigate wound

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching?

Poor nutritional status, obesity, wound infection

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

Schedule a follow-up visit by a home health nurse for dressing changes.

A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching?

Vitamin A, B12, C, K

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Perform neurovascular checks of the extremities.

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?

Report of exposure to a skin irritant.