ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?
- A. Administer pain medication
- B. Use proper hand hygiene and strict infection control
- C. Delegate all client personal care to specific unlicensed assistive personnel
- D. Plate the client in contact precautions
Correct answer: B
Rationale:
2. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?
- A. Two-point gait
- B. Three-point gait
- C. Four-point gait
- D. Unaffected gait
Correct answer: B
Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.
3. Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?
- A. I can spread this through contact with surfaces, so I need to wear gloves in public.'
- B. Because I have HIV, that means I'm an AIDS patient'
- C. I need to ensure that I place my needles in a proper needle disposal container.'
- D. I can still have unprotected intercourse with my partner since he does not have HIV.'
Correct answer: C
Rationale:
4. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?
- A. Amputation
- B. Deep vein thrombosis
- C. Internal bleeding
- D. Kidney failure
Correct answer: B
Rationale:
5. What nursing interventions increase the risk the pressure injuries?
- A. Padding hard surfaces
- B. Have client sit in wheelchair as much as possible
- C. Place pillows between bony surfaces
- D. Keep head of bed (HOB) at or less than 3
Correct answer: B
Rationale:
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