ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?
- A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
- B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
- C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
- D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'
Correct answer: A
Rationale:
2. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?
- A. Because it is easy to digest.'
- B. Protein has amin acid that promotes wound healing.'
- C. If you do not like it, you do not have to take it.'
- D. These supplements have nothing to do with your wound,'
Correct answer: B
Rationale:
3. What is a negative effect of immobility on the cardiovascular system?
- A. Increased high density lipoprotein
- B. Increased circulation
- C. Increased pumping action of the heart
- D. Venous stasis
Correct answer: D
Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.
4. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?
- A. The client reports chronic fatigue
- B. The client has a butterfly rash
- C. Blood pressure of 126/85 mm Hg
- D. Urine output of 20 mL/hour
Correct answer: D
Rationale:
5. The following client come to the ophthalmology clinic. Which client needs to be seen first?
- A. Client who had recent cataract surgery and has worsening vision
- B. Client with an absent red reflex on ophthalmic examination
- C. Client with an intraocular pressure of 24 mm Hg
- D. Client with a tearing, reddened eye with exudate
Correct answer: A
Rationale: Worsening vision after cataract surgery requires immediate attention to prevent complications.
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