ATI RN
Multi Dimensional Care | Final Exam
1. A client has a new arm cast. What is incorrect teaching by the nurse?
- A. Use a sling to alleviate fatigue
- B. Elevate the arm above the heart to reduce swelling
- C. Report ‘hot spots’ felt under the cast
- D. Sudden increase in drainage is expected
Correct answer: D
Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
2. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?
- A. The pain will go away after the swelling decreases.
- B. That is phantom limb pain.
- C. Your foot has been amputated, so you are not having pain in that foot.
- D. On a scale of 0-10, how would you rate your pain?
Correct answer: D
Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.
3. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?
- A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
- B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
- C. The UAP carefully empties the indwelling catheter bag
- D. The UAP shows the client how to use the call light
Correct answer: A
Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.
4. What nursing intervention is best to improve communication with a hearing-impaired client?
- A. Speak slowly and clearly while facing the client
- B. Write down the message
- C. Talk in a regular voice in the good ear
- D. Shout in the impaired
Correct answer: A
Rationale: Speaking slowly and clearly while facing the client improves communication with hearing-impaired clients.
5. 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:
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