ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?
- A. Because it is easy to digest.'
- B. Protein has amin acid that promotes wound healing.'
- C. If you do not like it, you do not have to take it.'
- D. These supplements have nothing to do with your wound,'
Correct answer: B
Rationale:
2. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?
- A. 15 degrees
- B. 0 degrees
- C. 90 degrees
- D. 30 degrees
Correct answer: C
Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.
3. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?
- A. Send the client back to surgery
- B. Assess the wound for signs of dehiscence
- C. Call the provider immediately
- D. Prepare to culture the wound
Correct answer: B
Rationale:
4. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?
- A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
- B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
- C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
- D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'
Correct answer: A
Rationale:
5. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?
- A. Amount
- B. Consistency
- C. Heat
- D. Odor
Correct answer: C
Rationale:
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