ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What does CREST stand for?
- A. Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly and Telecines
- B. Calcinosis, Reverse isolation, Esophageal dysmotility, Sclerodactyly and Telangiectasia
- C. Calcinosis, Raynaud's, Everted colon, Sclerodactyly and Telangiectasia
- D. Calcinosis, Raynaud's Esophageal dysmotility, Sclerodactyly and telangiectasia
Correct answer: D
Rationale:
2. 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:
3. What is a priority intervention when caring for a client in Buck’s traction?
- A. Adjust the size of the traction weights PRN as needed
- B. Discontinue the traction once the client has pain relief
- C. Ensure the traction weights rest on the floor
- D. Assess skin integrity
Correct answer: D
Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.
4. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?
- A. An adolescent who has a patella fracture and is in an immobilizer
- B. A young adult who has a femur fracture and is going to surgery in two hours
- C. A middle-aged adult who has fractured his radius and has a cast
- D. An older adult who has a hip fracture and is immobile
Correct answer: D
Rationale:
5. A nurse assesses an audible grating sound (Crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?
- A. A herniated disk in the diseased joint
- B. Pieces of bone and cartilage floating
- C. Popping bursae from standing
- D. Years of an autoimmune process
Correct answer: A
Rationale:
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