ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
- A. Position the client on one side with the head turned towards you
- B. Handle dentures with care
- C. Use gentle brushing and flossing techniques for clients with fragile mucosa
- D. Have a suction apparatus ready at the bedside
Correct answer: A
Rationale:
2. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
- A. The nurse assesses capillary refill of 2 seconds
- B. The nurse cannot insert one finger between the cast and the skin
- C. The nurse finds 2+ pulses distal from the cast
- D. The nurse does not observe any drainage
Correct answer: B
Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.
3. What is correct about a nursing diagnosis?
- A. It is a human response to disease, injury, or other stressors.
- B. It remains constant as long as the disease is present.
- C. It is a way to identify pathology.
- D. It is a disease, illness, or injury.
Correct answer: A
Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.
4. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?
- A. Avoid contact sports until the infection has cleared
- B. Use a bath sponge to cleanse the skin
- C. Wash hands with soap and water before and after touching the infected area
- D. Use an antibacterial soap when showering
Correct answer: B
Rationale:
5. A client has a fractured right arm. What should the nurse do first?
- A. Apply ice to the fracture site
- B. Administer pain medications
- C. Remove the client’s bracelet and rings from the right arm
- D. Send the client to radiology for an x-ray
Correct answer: C
Rationale: The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.
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