ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A man has been admitted to the hospital unit with a medical diagnosis of COPD. He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing?
- A. Prone position
- B. Sim's position
- C. Lateral position
- D. Fowler's position
Correct answer: D
Rationale:
2. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
- A. Use a mechanical lift to reposition the client every 2 hours
- B. Elevate the client's head of the bed to 45 degrees
- C. Postpone daily bed bath
- D. Caregiver independently slides the client up in the bed
Correct answer: A
Rationale:
3. Which finding is not typically associated with inflammation in a client?
- A. Pain
- B. Heat
- C. Polyuria
- D. Erythema
Correct answer: C
Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.
4. A client has AIDS. Which of these findings indicate possible infection?
- A. Respirations; 22 breaths per minute
- B. Client ambulates 20 feet
- C. Purulent drainage
- D. Oxygen saturation; 97% on room air
Correct answer: C
Rationale:
5. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?
- A. Label the specimen tube
- B. Put on non-sterile gloves
- C. Gently remove the soiled dressings
- D. Irrigate the wound
Correct answer: B
Rationale:
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