ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?
- A. Hyperthermia
- B. A cold environment
- C. Normal
- D. Hypothermia
Correct answer: A
Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.
2. What phase of wound healing occurs at the time of injury and lasts about 3-5 days?
- A. Maturation
- B. Intentional
- C. Inflammatory
- D. Proliferative
Correct answer: C
Rationale:
3. What health teaching would not help an older adult avoid a musculoskeletal injury?
- A. Avoid home modification
- B. Wear a helmet when riding a bicycle
- C. Osteoporosis screening
- D. Fall prevention
Correct answer: A
Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.
4. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?
- A. The client sets the cap down in a manner that does not contaminate it.
- B. The client drops the prescribed number of drops into the conjunctival sac
- C. The client washes their hands before instilling the drops
- D. The client ensures that they touch the administration dropper to the eye
Correct answer: D
Rationale: Touching the dropper to the eye contaminates it and can lead to infection.
5. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer a protein rich diet
- C. Offer the client a bedpan for toileting
- D. Turn the client every 4 hours
Correct answer: A
Rationale: The orthopneic position helps improve lung expansion, reducing the risk of atelectasis.
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