ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present
Correct answer: D
Rationale:
2. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?
- A. Stage 3
- B. Stage 4
- C. Stage 1
- D. Stage 2
Correct answer: D
Rationale:
3. The client complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse?
- A. "You just have arthritis and should take some ibuprofen."?
- B. "You should avoid walking. This might be osteoporosis."?
- C. "Please tell me more about when your pain started."?
- D. "You need to lose weight or the pain won't go away."?
Correct answer: C
Rationale:
4. A nurse is teaching a client who has a new prescription for ibuprofen to treat rheumatoid arthritis. The nurse should teach the client to monitor for what adverse effect of this medication?
- A. Bleeding
- B. Insomnia
- C. Blurred vision
- D. Constipation
Correct answer: C
Rationale:
5. Which among the following is NOT the cause of pressure ulcers?
- A. Immobility
- B. Poor nutrition
- C. Moisture
- D. Adequate perfusion
Correct answer: D
Rationale:
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