ATI RN
Multi Dimensional Care | Final Exam
1. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?
- A. Inquire about the frequency, quality and location of the pain
- B. Get the client pain medication
- C. Ensure the client knows he will have negative effects from immobility
- D. Review the client’s medication administration record
Correct answer: A
Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.
2. What is a sign of inadequate perfusion?
- A. Intact sensation
- B. Pallor in toes
- C. Bounding pulses
- D. Pink fingers
Correct answer: B
Rationale:
3. A nurse is caring for an immobile client. What is the priority assessment of this client?
- A. Palpate for edema
- B. Auscultate for bowel sounds
- C. Inspect the skin for injury
- D. Auscultation of lung sounds
Correct answer: C
Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.
4. 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:
5. What is an example of a client's primary defense to infection?
- A. Intact skin
- B. Inflammation
- C. Phagocytosis
- D. Fever
Correct answer: A
Rationale:
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