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. Which organization publishes the National Patient Safety Goals?
- A. The Joint Commission
- B. Medicare
- C. The American Nurses Association
- D. The Institute of Medicine
Correct answer: A
Rationale:
3. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?
- A. "Ice packs can be used to reduce swelling but should be removed after 20 minutes."?
- B. "Heat always makes the swelling go down. You do not need any other interventions."?
- C. "Try high impact exercise exercise like running to loosen up your joints and reduce pain."?
- D. "Apply ice packs. It is generally okay to keep them on for up to one hour at a time."?
Correct answer: A
Rationale:
4. What nursing intervention is best to improve communication with a hearing-impaired client?
- A. Speak slowly and clearly while facing the client
- B. Write down the message
- C. Talk in a regular voice in the good ear
- D. Shout in the impaired
Correct answer: A
Rationale: Speaking slowly and clearly while facing the client improves communication with hearing-impaired clients.
5. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
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