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 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:
3. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?
- A. Skin turgor
- B. Lung sounds
- C. Radial pulses
- D. Capillary refill
Correct answer: B
Rationale:
4. The medical record for a client states that the client has hemiplegia. What does this mean?
- A. The client can use his right arm, left leg, and left arm.
- B. The client has paralysis of all four extremities.
- C. The client has decreased vision in one eye.
- D. The client has paralysis on one side of the body.
Correct answer: D
Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.
5. A nurse is teaching a client who has out about dietary recommendations. The nurse should teach the client which of the following beverages can trigger an attack?
- A. Fruit juice
- B. Alcohol
- C. Milk
- D. Coffee
Correct answer: B
Rationale:
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