ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?
- A. The client reports chronic fatigue
- B. The client has a butterfly rash
- C. Blood pressure of 126/85 mm Hg
- D. Urine output of 20 mL/hour
Correct answer: D
Rationale:
2. Where will the nurse collect the most reliable source of pain assessment?
- A. From the nurse-to-nurse bedside report
- B. From a medical surgical book
- C. From the client
- D. From the client's chart
Correct answer: C
Rationale:
3. A client recently had an above the knee amputation and complains of pain distal to the amputation. What type of pain is the client experiencing?
- A. Nociceptive
- B. Neuropathic
- C. Visceral
- D. Cutaneous
Correct answer: A
Rationale:
4. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?
- A. Observe client for changes in mental status
- B. Use aseptic technique for wound care and emptying of drains
- C. Keep the client's heels off the bed
- D. Perform neurovascular assessments per protocol
Correct answer: D
Rationale:
5. What is a negative effect of immobility on the musculoskeletal system?
- A. Pressure injury
- B. Contractures
- C. Glucose intolerance
- D. Incontinence
Correct answer: B
Rationale: Contractures are a negative effect of immobility on the musculoskeletal system.
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