ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What is a sign of inadequate perfusion?
- A. Intact sensation
- B. Pallor in toes
- C. Bounding pulses
- D. Pink fingers
Correct answer: B
Rationale:
2. 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:
3. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?
- A. I will drink at least 3000 mL of water daily."?
- B. . 'I will shower every day in hot water."?
- C. I will avoid tights belts."?
- D. I will use a humidifier during the winter months."?
Correct answer: B
Rationale:
4. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?
- A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
- B. "An injured artery causes impaired arterial perfusion through the compartment."?
- C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
- D. . "A bone fragment has injured the nerve supply in the area."?
Correct answer: C
Rationale:
5. What nursing interventions increase the risk the pressure injuries?
- A. Padding hard surfaces
- B. Have client sit in wheelchair as much as possible
- C. Place pillows between bony surfaces
- D. Keep head of bed (HOB) at or less than 3
Correct answer: B
Rationale:
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