ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct answer: D
Rationale:
2. What nursing intervention is best to improve communication with a hearingimpaired client?
- A. Talk in a regular voice in the good ear
- B. Talk loudly in the impaired ear
- C. Write down the message
- D. Speak slowly and clearly while facing the client
Correct answer: D
Rationale:
3. Which of the following clients should be placed in isolation for airborne precautions?
- A. A high school wrestling championship with a rash
- B. A client that recently travelled and developed a fever with cough
- C. A client with an unknown skin infection
- D. A client with heart palpitations
Correct answer: B
Rationale:
4. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
- A. Client will increase mobility by the time of discharge from hospital
- B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
- C. Client will increase activity tolerance by discharge from the hospital
- D. Client will remain free from falls throughout their hospital stay
Correct answer: D
Rationale:
5. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
- A. Assess the right radial pulse
- B. Call the provider
- C. Administer pain medication
- D. Assess the right pedal pulse
Correct answer: A
Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.
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