ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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:
2. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)
- A. A client on birth control pills
- B. A client who is immobile
- C. A client on an anticoagulant
- D. A client with dementia who has been wandering
Correct answer: a
Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.
3.
- A. Hyperthermia
- B. A cold environment
- C. Normal
- D. Hypothermia
Correct answer: A
Rationale:
4. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?
- A. Observe client for changes in mental status
- B. Use aseptic technique for wound care and emptying of drains
- C. Keep the client's heels off the bed
- D. Perform neurovascular assessments per protocol
Correct answer: D
Rationale:
5. The nurse is caring for 4 clients. Which of these clients will the nurse see first?
- A. A client with rheumatoid arthritis and a scheduled pain medication
- B. A client being discharged in 2 hours and needs to be taught how to use crutches
- C. A client with sudden and increasing pain in a fractured arm
- D. A client with a fractured ankle who would like a glass of water
Correct answer: C
Rationale: The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage. Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.
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