ATI RN
Multi Dimensional Care | Final Exam
1. 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.
2. 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.
3. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?
- A. Ischial tuberosity
- B. Compartment syndrome
- C. Broken arm syndrome
- D. Pulmonary embolism
Correct answer: B
Rationale:
4. Which test is used in the diagnosis of osteoporosis?
- A. Phalen's maneuver
- B. Dual-energy X-ray absorptiometry (DXA) scan
- C. Proprioception
- D. Blood culture
Correct answer: B
Rationale: The correct answer is B, Dual-energy X-ray absorptiometry (DXA) scan, which is commonly used to diagnose osteoporosis by measuring bone mineral density. Phalen's maneuver (choice A) is a test used to assess for carpal tunnel syndrome and is not related to osteoporosis. Proprioception (choice C) refers to the sense of body position and is not a diagnostic test for osteoporosis. Blood culture (choice D) is used to detect infections caused by bacteria in the bloodstream and is not relevant to the diagnosis of osteoporosis.
5. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct answer: D
Rationale:
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