ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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?
- A. Color
- B. Temperature
- C. Sensation
- D. Skin integrity
Correct answer: D
Rationale:
2. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?
- A. Label the specimen tube
- B. Put on non-sterile gloves
- C. Gently remove the soiled dressings
- D. Irrigate the wound
Correct answer: B
Rationale:
3. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?
- A. Send the client back to surgery
- B. Assess the wound for signs of dehiscence
- C. Call the provider immediately
- D. Prepare to culture the wound
Correct answer: B
Rationale:
4. 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.
5. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?
- A. Deeply palpate the area for rebound tenderness
- B. Medicate the client for pain and reassess in 60 minutes
- C. Percuss over the area for a change in tone
- D. Compare the circumference to the left calf
Correct answer: D
Rationale:
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