ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?
- A. Send the client back to surgery
- B. Assess the wound for signs of dehiscence
- C. Call the provider immediately
- D. Prepare to culture the wound
Correct answer: B
Rationale:
2. What is an example of proper body mechanics when lifting?
- A. Lifting the object with your back
- B. Standing with a narrow stance
- C. Lifting excessive weight to strengthen the muscles
- D. Holding the object close to the body
Correct answer: D
Rationale: Proper body mechanics include holding objects close to the body to prevent injury.
3. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?
- A. Insert the wound and assess the drainage
- B. Apply topical ointment to the wound
- C. Call the provider to initiate antibiotics
- D. Culture the wound
Correct answer: D
Rationale:
4. What is the priority nursing diagnosis for a client with immobility?
- A. Constipation related to immobility
- B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
- D. Risk for disuse syndrome as evidenced by immobility
Correct answer: C
Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.
5. What is the most common method of reducing and immobilizing a fracture?
- A. Open reduction with external fixation
- B. External reduction and internal fixation
- C. External fixation with closed reduction
- D. Open reduction with internal fixation
Correct answer: D
Rationale: Open reduction with internal fixation (ORIF) is the most common method for reducing and immobilizing fractures.
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