ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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:
2. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?
- A. Deeply palpate the area for rebound tenderness
- B. Medicate the client for pain and reassess in 60 minutes
- C. Percuss over the area for a change in tone
- D. Compare the circumference to the left calf
Correct answer: D
Rationale:
3. What is the nurse's priority action for a client with compromised immunity?
- A. Wash hands before entering the client's room
- B. Take the client's vital signs every 4 hours
- C. Determine whether it is temporary or permanent
- D. Teach the family members to receive the flu shot annually
Correct answer: A
Rationale:
4. What level of Maslow's Hierarchy of needs does shelter belong to?
- A. Love and belonging
- B. Physiological
- C. Safety and security
- D. Esteem
Correct answer: C
Rationale:
5. The nurse is caring for a 65-year-old client and notes a temperature of 101°F. How does the nurse interpret this finding?
- A. Hyperthermia
- B. A cold environment
- C. Normal
- D. Hypothermia
Correct answer: A
Rationale: A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.
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