ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?
- A. Administer pain medication
- B. Use proper hand hygiene and strict infection control
- C. Delegate all client personal care to specific unlicensed assistive personnel
- D. Plate the client in contact precautions
Correct answer: B
Rationale:
2. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?
- A. The client is in a private room.
- B. The client has a vase of fresh flowers on the table
- C. The client has a dedicated vital signs machine
- D. There is hand sanitizer by the door
Correct answer: B
Rationale:
3. What steps are NOT included in preparing a sterile field?
- A. Do not turn away from the sterile field
- B. Obtain PAPR mask
- C. Prepare the client before setting up the sterile field
- D. Cover the sterile field once it is set up
Correct answer: B
Rationale:
4. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
- A. Use a mechanical lift to reposition the client every 2 hours
- B. Elevate the client's head of the bed to 45 degrees
- C. Postpone daily bed bath
- D. Caregiver independently slides the client up in the bed
Correct answer: A
Rationale:
5. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?
- A. Hyperthermia
- B. A cold environment
- C. Normal
- D. Hypothermia
Correct answer: A
Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.
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