ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is caring for an immobile client. What is the priority assessment in this client?
- A. Auscultation of lung sounds
- B. Assessment of skin turgor
- C. Auscultation of bowel sounds
- D. Assessment for the presence of peripheral edema
Correct answer: A
Rationale:
2. To promote independence, which of these is the best intervention to implement?
- A. Perform the client’s activities of daily living for them.
- B. Speak directly in front of the client so they can read your lips well.
- C. Give the client their washcloth and toothbrush and leave the room.
- D. Allow the client to perform the activities of daily living they are able to do.
Correct answer: D
Rationale: The correct answer is to allow the client to perform the activities of daily living they are able to do. This intervention promotes independence by encouraging clients to maintain their functional abilities. Choice A is incorrect as performing the client's activities of daily living for them does not empower independence. Choice B is irrelevant to promoting independence. Choice C is not actively promoting independence as it involves leaving the client alone without any guidance or support.
3. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
- A. Assess the right radial pulse
- B. Call the provider
- C. Administer pain medication
- D. Assess the right pedal pulse
Correct answer: A
Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.
4. Why is traction used?
- A. It allows the bones to realign
- B. It decreases the risk of misalignment
- C. It promotes wound healing
- D. It allows the client to rest longer
Correct answer: A
Rationale: Traction is used to help align the bones properly during the healing process. Choice A is correct because traction assists in allowing the bones to realign correctly, promoting proper healing. Choice B is incorrect as traction does not decrease the risk of misalignment; instead, it helps reduce misalignment by aiding in bone alignment. Choice C is incorrect because while traction indirectly supports wound healing by ensuring proper bone alignment, its primary purpose is not wound healing. Choice D is incorrect as the primary purpose of traction is not to allow the client to rest longer, but rather to aid in bone alignment for optimal healing.
5. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?
- A. Amputation
- B. Deep vein thrombosis
- C. Internal bleeding
- D. Kidney failure
Correct answer: B
Rationale:
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