ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?
- A. Insert the wound and assess the drainage
- B. Apply topical ointment to the wound
- C. Call the provider to initiate antibiotics
- D. Culture the wound
Correct answer: D
Rationale:
2. What is the best nursing intervention for a client with limited mobility who cannot move independently?
- A. Passive range of motion
- B. Pillows for positioning
- C. Active range of motion
- D. Continuous passive motion
Correct answer: A
Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.
3. A client has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?
- A. Primary intention
- B. Binary intention
- C. Secondary intention
- D. None of the Above
Correct answer: A
Rationale:
4. What does CREST stand for?
- A. Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly and Telecines
- B. Calcinosis, Reverse isolation, Esophageal dysmotility, Sclerodactyly and Telangiectasia
- C. Calcinosis, Raynaud's, Everted colon, Sclerodactyly and Telangiectasia
- D. Calcinosis, Raynaud's Esophageal dysmotility, Sclerodactyly and telangiectasia
Correct answer: D
Rationale:
5. A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
- A. Administer glucosamine supplements
- B. Turn the client every 2 hours
- C. Provide active range of motion (ROM)
- D. Provide passive range of motion (ROM)
Correct answer: D
Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.
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