ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?
- A. Amputation
- B. Deep vein thrombosis
- C. Internal bleeding
- D. Kidney failure
Correct answer: B
Rationale:
2. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?
- A. Offer the client protein with meals to promote healing
- B. Remove the old dressing with clean gloves
- C. Teach the client about nonpharmacological pain control methods
- D. Check medication administration record (MAR)for as needed orders (PRN)
Correct answer: C
Rationale:
3. Which among the following is NOT the cause of pressure ulcers?
- A. Immobility
- B. Poor nutrition
- C. Moisture
- D. Adequate perfusion
Correct answer: D
Rationale:
4. What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmission-based precautions?
- A. Allow the client sleep to build stamina
- B. Provide the client with diversional activities
- C. Maintain a six-foot distance from the client
- D. Provide a timeframe for the isolation
Correct answer: B
Rationale:
5. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present
Correct answer: D
Rationale:
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