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. A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?
- A. Delegate all client personal care to specific unlicensed assistive personnel
- B. Place the client in contact precautions
- C. Proper hand hygiene
- D. Administer pain medication
Correct answer: C
Rationale: Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.
3. A client with a diagnosis of Human Immunodeficiency Virus develops pneumonia. What type of infection is this?
- A. An opportunistic infection
- B. A root cause infection
- C. A pathogenic infection
- D. A nosocomial infection
Correct answer: A
Rationale: The correct answer is A: An opportunistic infection. In patients with Human Immunodeficiency Virus (HIV), infections like pneumonia are considered opportunistic because they take advantage of a weakened immune system. Option B, root cause infection, is incorrect as it does not describe the nature of the infection in relation to the patient's condition. Option C, pathogenic infection, is incorrect because while pneumonia is caused by pathogens, in the context of HIV, it is specifically termed as an opportunistic infection. Option D, nosocomial infection, is also incorrect as it refers to infections acquired in a healthcare setting, not related to the patient's HIV status.
4. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?
- A. Wearing a mask within three feet of the client
- B. Using standard precautions
- C. Applying hand sanitizer to gloves during cares
- D. Double gloving
Correct answer: B
Rationale:
5. 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?
- A. The client's incision site has eviscerated
- B. The client's incision site has lacerated
- C. The client's incisional site is approximated
- D. The client's incisional site has dehisced after.
Correct answer: A
Rationale:
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