ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is in skeletal traction. With the nurse’s assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?
- A. Collect a culture of the purulent fluid
- B. Cleanse the skin around the pins
- C. Administer an antibiotic
- D. Instruct the client to complete exercise of the affected extremity
Correct answer: Collect a culture of the purulent fluid
Rationale:
2. A nurse is caring for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following interventions should the nurse include in the plan of care?
- A. Place the client in a well-lit area to reduce wandering.
- B. Use physical restraints to prevent wandering.
- C. Ensure that the client wears an identification bracelet at all times.
- D. Keep the client's bed in the lowest position.
Correct answer: C
Rationale: The correct intervention for a client with Alzheimer's disease who demonstrates confusion and wandering behavior is to ensure that the client wears an identification bracelet at all times. This helps prevent wandering and ensures the client's safety. Placing the client in a well-lit area may be beneficial for orientation but does not directly address wandering behavior. Using physical restraints is not recommended as it can lead to agitation and other complications. Keeping the client's bed in the lowest position is important for fall prevention but does not specifically address the issue of wandering behavior.
3. 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: Using standard precautions
Rationale:
4. The client on amiodarone reports shortness of breath. What is the nurse’s best response?
- A. Notify the healthcare provider immediately.
- B. Reassure the client that this is a common side effect.
- C. Instruct the client to monitor their symptoms at home.
- D. Suggest the client reduce physical activity.
Correct answer: A
Rationale: When a client on amiodarone reports shortness of breath, it can be indicative of pulmonary toxicity, a severe side effect associated with this medication. The nurse's priority is to notify the healthcare provider immediately to assess the situation and determine the appropriate course of action. Choice B is incorrect because shortness of breath with amiodarone should not be dismissed as a common side effect. Instructing the client to monitor symptoms at home (Choice C) may delay necessary intervention. Suggesting the client reduce physical activity (Choice D) does not address the potential serious nature of the symptom and the need for prompt evaluation.
5. What is the primary purpose of administering an antiemetic?
- A. To reduce nausea and vomiting
- B. To increase appetite
- C. To treat nausea caused by chemotherapy
- D. To treat allergic reactions
Correct answer: A
Rationale: The correct answer is A: 'To reduce nausea and vomiting.' Antiemetics are medications used to prevent or alleviate nausea and vomiting. While they may indirectly help with appetite by reducing the unpleasant symptoms that can lead to decreased food intake, their primary purpose is not to increase appetite (Choice B). Choice C, 'To treat nausea caused by chemotherapy,' is partly correct as antiemetics are commonly used to manage chemotherapy-induced nausea, but this is not their exclusive purpose. Choice D, 'To treat allergic reactions,' is incorrect as antiemetics are not primarily used for treating allergic reactions.
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