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. What are signs of hearing loss? (Select all that apply)
- A. Answering questions correctly
- B. Presence of cerumen
- C. Tinnitus
- D. Frequent asking of others to repeat statements
Correct answer: C
Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.
3. The nurse is providing medication for a client with osteomyelitis. What teaching should the nurse indicate in the education?
- A. The most common adverse e effect for nonsteroidal anti-inflammatory drugs (NSAIDS)are liver failure and tinnitus
- B. The main side effect of acetaminophen is gastrointestinal GI bleeding
- C. You should not take more than 4000 mg of acetaminophen a day
- D. Nonsteroidal anti-inflammatory drugs (NSAIDS) are very safe and are known to have no side effects
Correct answer: A
Rationale:
4. 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.
5. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?
- A. Ischial tuberosity
- B. Compartment syndrome
- C. Broken arm syndrome
- D. Pulmonary embolism
Correct answer: B
Rationale:
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