ATI RN
Multi Dimensional Care | Final Exam
1. A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?
- A. Delegate all client personal care to specific unlicensed assistive personnel
- B. Place the client in contact precautions
- C. Proper hand hygiene
- D. Administer pain medication
Correct answer: C
Rationale: Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.
2. 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.
3. A nurse is providing teaching to an older client who has osteoarthritis that is affecting the knees. What statement by the client indicates a correct understanding of the teaching?
- A. I can use either heat or ice to help relieve the discomfort
- B. The purpose of drug therapy is to stop the disease progression.'
- C. I will start a daily running program to get more exercise.'
- D. I should avoid physical activity to prevent further injury.'
Correct answer: A
Rationale:
4. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?
- A. Remove the cast to decrease pressure
- B. Raise the arm above the level of the heart
- C. Apply heat to the affected hand
- D. Encourage range of motion
Correct answer: B
Rationale:
5. What is a sign of inadequate perfusion?
- A. Intact sensation
- B. Pallor in toes
- C. Bounding pulses
- D. Pink fingers
Correct answer: B
Rationale:
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