ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer the client a bedpan for toileting
- C. Offer a protein-rich diet
- D. Turn the client every 2 hours
Correct answer: Turn the client every 2 hours
Rationale:
2. After surgery, your patient starts to shiver uncontrollably. What nursing intervention would you do first?
- A. Apply warm blankets & continue oxygen as prescribed
- B. Take the patient's rectal temperature
- C. Page the doctor for further orders
- D. Adjust the thermostat in the room
Correct answer: Apply warm blankets & continue oxygen as prescribed
Rationale: When a patient starts shivering uncontrollably after surgery, the priority nursing intervention is to apply warm blankets and continue oxygen as prescribed. Shivering can be a sign of hypothermia, and maintaining the patient's body temperature is crucial for their recovery. This intervention helps prevent further heat loss and supports the patient's comfort and safety. While monitoring temperature, paging the doctor, and adjusting the room temperature may be necessary, addressing the immediate need for warmth and oxygen is the priority in this situation.
3. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?
- A. Tunnelling
- B. Eschar
- C. Blanching
- D. Cellulitis
Correct answer: Eschar
Rationale:
4. When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that:
- A. Medications provided are ineffective.
- B. Nurses are trying to control their minds.
- C. The medications will make them sick.
- D. They are not actually ill.
Correct answer: D
Rationale: Anosognosia is a lack of insight that affects patients with schizophrenia, leading them to deny or lack awareness of their illness. This lack of awareness often results in patients refusing medication because they genuinely believe they are not ill and do not need treatment. It is crucial for healthcare providers to approach such situations with understanding and empathy, recognizing the impact of anosognosia on treatment adherence.
5. A client is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
- A. Prime IV tubing with 0.9% sodium chloride
- B. Use a 24-gauge IV catheter
- C. Obtain filterless IV tubing
- D. Place blood in the warmer for 1 hr
Correct answer: A: Prime IV tubing with 0.9% sodium chloride
Rationale: Prior to administering a blood transfusion, it is essential to prime the IV tubing with 0.9% sodium chloride to prevent hemolysis of the blood cells. Using a smaller gauge IV catheter (e.g., 20 or 22 gauge) is recommended for blood transfusions to prevent hemolysis. Filterless IV tubing is contraindicated for blood transfusions as it does not have a filter to trap potential blood clots or debris. Warming blood is unnecessary and could lead to the development of bacteria in the blood product. Therefore, the correct action for the nurse to take is to prime the IV tubing with 0.9% sodium chloride.
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