ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?
- A. Remove the cast to decrease pressure
- B. Raise the arm above the level of the heart
- C. Apply heat to the affected hand
- D. Encourage range of motion
Correct answer: B
Rationale:
2. What phase of wound healing occurs at the time of injury and lasts about 3-5 days?
- A. Maturation
- B. Intentional
- C. Inflammatory
- D. Proliferative
Correct answer: C
Rationale:
3. A client has a fractured right arm. What should the nurse do first?
- A. Apply ice to the fracture site
- B. Administer pain medications
- C. Remove the client’s bracelet and rings from the right arm
- D. Send the client to radiology for an x-ray
Correct answer: C
Rationale: The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.
4. What may be a cause of conductive hearing loss?
- A. Prolonged exposure to loud noises
- B. Medications
- C. Presbycusis
- D. Otitis media
Correct answer: D
Rationale: Otitis media can cause conductive hearing loss by affecting the middle ear.
5. What is the priority nursing diagnosis after surgery to repair a fracture?
- A. Disturbed body image
- B. Risk for infection
- C. Risk for impaired skin integrity
- D. Acute pain
Correct answer: B
Rationale: The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.
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