ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?
- A. Send the client back to surgery
- B. Assess the wound for signs of dehiscence
- C. Call the provider immediately
- D. Prepare to culture the wound
Correct answer: B
Rationale:
2. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
- A. Position the client on one side with the head turned towards you
- B. Handle dentures with care
- C. Use gentle brushing and flossing techniques for clients with fragile mucosa
- D. Have a suction apparatus ready at the bedside
Correct answer: A
Rationale:
3. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?
- A. Wearing a mask within three feet of the client
- B. Intentional
- C. Using standard precautions
- D. Proliferative
Correct answer: C
Rationale:
4. A client has a fractured right arm. What should the nurse do first?
- A. Apply ice to the fracture site
- B. Administer pain medications
- C. Remove the client’s bracelet and rings from the right arm
- D. Send the client to radiology for an x-ray
Correct answer: C
Rationale: The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.
5. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?
- A. I will drink at least 3000 mL of water daily."?
- B. . 'I will shower every day in hot water."?
- C. I will avoid tights belts."?
- D. I will use a humidifier during the winter months."?
Correct answer: B
Rationale:
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