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. A nurse is teaching a newly hired group of unlicensed assistive personnel about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care?
- A. Properly dispose of contaminated equipment
- B. Perform hand hygiene
- C. Discard used syringes into appropriate containers
- D. Change soiled linens
Correct answer: B
Rationale:
3. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
4. What lifestyle habits positively affect skin integrity?
- A. Regular exercise
- B. Tattoos
- C. Smoking
- D. Tanning
Correct answer: A
Rationale:
5. A nurse is caring for an immobile client. What is the priority assessment in this client?
- A. Auscultation of lung sounds
- B. Assessment of skin turgor
- C. Auscultation of bowel sounds
- D. Assessment for the presence of peripheral edema
Correct answer: A
Rationale:
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