Free Multi Dimensional Care practice for Multi Dimensional Care | Exam | Rasmusson (ATI RN). Answer 75 nursing exam-style questions with rationales, exam mode,
The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
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Explanation:
Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.
A nurse is caring for an immobile client. What is the priority assessment in this client?
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Explanation:
The client with systemic sclerosis (Scleroderma) is experiencing Raynaud's phenomenon. What assessment finding does the nurse anticipate?
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Explanation:
What is an infectious disease that can be transmitted directly from one person to another?
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Explanation:
A client just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy?
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Explanation:
The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?
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Explanation:
The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.
Which client is at highest risk of compromised immunity?
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Explanation:
The medical record for a client states that the client has hemiplegia. What does this mean?
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Explanation:
Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.
What is the best nursing intervention for a client with limited mobility who cannot move independently?
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Explanation:
The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.
A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?
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Explanation:
What is not an inappropriate nursing intervention for psoriasis?
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Explanation:
Antibodies are passed from mother to fetus through the placenta. What is this type of immunity called?
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The client had surgery one day ago. What assessment is most likely related to pain?
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The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?
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A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?
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Explanation:
Which of the following assessments is found in neurovascular compromise?
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Explanation:
Tingling is a common sign of neurovascular compromise.
A nurse assesses an audible grating sound (Crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?
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Explanation:
A client has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?
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Explanation:
What are nonsurgical treatment options for carpal tunnel syndrome? (Select all that apply)
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Explanation:
The correct answer is D, 'All of the above.' Non-surgical treatments for carpal tunnel syndrome include using a splint, ultrasound therapy, corticosteroid injections, and NSAIDs. Choice A is correct as using a splint helps to keep the wrist in a neutral position, reducing pressure on the median nerve. Choice B is correct as ultrasound therapy can help reduce inflammation and alleviate symptoms. Choice C, 'Endoscopic carpal tunnel release,' is incorrect as it is a surgical procedure, not a nonsurgical treatment option for carpal tunnel syndrome.
What nursing intervention is best to improve communication with a hearing-impaired client?
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Explanation:
Speaking slowly and clearly while facing the client improves communication with hearing-impaired clients.
What health teaching would not help an older adult avoid a musculoskeletal injury?
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Explanation:
Avoiding home modifications can increase the risk of falls and injuries in older adults.
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?
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Explanation:
What is the best goal for pain control in a client with RA?
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The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?
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Explanation:
A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
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Explanation:
Assessing the radial pulse checks for adequate circulation and potential complications.
What is a sign of inadequate perfusion?
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Explanation:
A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
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Explanation:
What client is a susceptible host most at risk for infection?
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Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?
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Explanation:
Which of the following clients should be placed in isolation for airborne precautions?
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Explanation:
What statement by the client indicates a correct understanding of the timing of progression of human immunodefiency virus (HIV) to acquired immunodeficiency syndrome?
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The nurse is caring for 4 clients. Which of these clients will the nurse see first?
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Explanation:
A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?
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Explanation:
A client with systemic lupus erythematous complains of flank pain. Which laboratory test does the nurse anticipate will be ordered?
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Explanation:
What is the nurse's priority action for a client with compromised immunity?
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Explanation:
Which nonpharmacological intervention does not help reduce edema?
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Explanation:
The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.
The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
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Explanation:
Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.
A nurse is caring for a client who is post-operative following an open reduction internal fixation (ORIF) of a femur fracture. What is NOT included in the evaluation of the neurovascular status of the client's affected extremity?
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Explanation:
What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?
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Explanation:
The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.
A man has been admitted to the hospital unit with a medical diagnosis of COPD. He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing?
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Explanation:
The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
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Explanation:
The orthopneic position helps improve lung expansion, reducing the risk of atelectasis.
What medication class can decrease tissue inflammation but delays bone healing?
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Explanation:
The correct answer is B: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to decrease tissue inflammation but may delay bone healing. Anticoagulants (Choice A) are used to prevent blood clotting, opioids (Choice C) are pain relievers, and narcotics (Choice D) are drugs that affect the central nervous system. While all the choices may have their own indications and uses in healthcare, NSAIDs are specifically associated with delaying bone healing despite their anti-inflammatory properties.
A nurse is caring for an immobile client. What is the priority assessment of this client?
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Explanation:
Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.
What is one of the earliest signs of fat embolism syndrome?
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Explanation:
Hypoxemia is one of the earliest signs of fat embolism syndrome. In fat embolism syndrome, fat globules enter the bloodstream and can obstruct blood flow in the lungs, leading to hypoxemia. Paresthesia, severe pain unrelieved by medication, and edema are not typically among the earliest signs of fat embolism syndrome.
Most adults with human immunodeficiency virus will exhibit which of the following laboratory values?
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Explanation:
Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?
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Explanation:
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?
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Explanation:
What is correct health promotion education for vision? (Select all that apply)
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Explanation:
Wearing sunglasses, washing hands before touching eyelids, and wearing eye protection when working with fluids are important health promotion activities for vision.
The nurse is performing a psychosocial assessment on a client with a severe rheumatoid arthritis. What would be the most appropriate statement by the nurse?
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Explanation:
The client has been asked to perform weight-bearing exercises three times a week. The client admits to not doing the recommended exercises. What is the most appropriate response by the nurse?
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Explanation:
The most appropriate response by the nurse is to ask the client to elaborate on their experience with the exercises. By doing so, the nurse can gain insight into any barriers the client may be facing and work together to find solutions to improve adherence. Choice A is not appropriate as it doesn't address the client's situation. Choice C is not relevant and may induce fear in the client. Choice D is directive and does not promote open communication or understanding of the client's perspective.
What lifestyle habits positively affect skin integrity?
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Explanation:
What health teaching would not help an older adult avoid a musculoskeletal injury?
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Explanation:
Avoiding home modifications can increase the risk of falls and injuries in older adults.
A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?
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Explanation:
What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?
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Explanation:
A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?
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Explanation:
Which finding is not typically associated with inflammation in a client?
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Explanation:
Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.
While completing a health history the client reports experiencing blurring of vision in both eyes without associated pain. What condition does the nurse suspect?
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Explanation:
Cataracts can cause blurring of vision in both eyes without associated pain.
What level of Maslow's Hierarchy of needs does shelter belong to?
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Explanation:
Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?
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Explanation:
A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?
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Explanation:
The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.
An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?
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Explanation:
What evaluation indicates successful progress on the client goal of increasing daily physical activity?
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Explanation:
The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.
What is a negative effect of immobility on the cardiovascular system?
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Explanation:
Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.
What is the intended outcome for the treatment of glaucoma?
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Explanation:
The correct answer is C: Lower the intraocular pressure. The primary objective of treating glaucoma is to reduce intraocular pressure to prevent further vision loss. Choice A, 'Improve the vision of the eye,' is incorrect because while treatment may prevent vision loss, it does not necessarily improve vision. Choice B, 'Strengthen the muscles of the eye,' is incorrect as glaucoma primarily involves the optic nerve and not muscle weakness. Choice D, 'Dry up excess secretions,' is not related to the treatment goal of glaucoma which is focused on managing intraocular pressure.
What should be done immediately after an ankle injury?
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Explanation:
The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.
The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?
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Explanation:
Touching the dropper to the eye contaminates it and can lead to infection.
What are some of the expected outcomes when medications are given for rheumatoid arthritis?
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Explanation:
What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?
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Explanation:
The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?
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Explanation:
A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?
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Explanation:
A client has suffered from a femur fracture. What is the nurse's priority assessment?
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Explanation:
What is a priority intervention when caring for a client in Buck's traction?
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Explanation:
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.
To promote independence, which of these is the best intervention to implement?
Select the best answer.
Explanation:
The correct answer is to allow the client to perform the activities of daily living they are able to do. This intervention promotes independence by encouraging clients to maintain their functional abilities. Choice A is incorrect as performing the client's activities of daily living for them does not empower independence. Choice B is irrelevant to promoting independence. Choice C is not actively promoting independence as it involves leaving the client alone without any guidance or support.
What is a priority intervention when caring for a client in Buck's traction?
Select the best answer.
Explanation:
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.
To promote independence, which of these is the best intervention to implement?
Select the best answer.
Explanation:
The correct answer is to allow the client to perform the activities of daily living they are able to do. This intervention promotes independence by encouraging clients to maintain their functional abilities. Choice A is incorrect as performing the client's activities of daily living for them does not empower independence. Choice B is irrelevant to promoting independence. Choice C is not actively promoting independence as it involves leaving the client alone without any guidance or support.
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