ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?
- A. Administer antibiotics to the client
- B. Increase the client's protein intake
- C. Teach relaxation breathing to reduce the client's pain
- D. Provide the client with anti-pyretic therapy
Correct answer: A
Rationale:
2. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?
- A. Stage 3
- B. Stage 4
- C. Stage 1
- D. Stage 2
Correct answer: D
Rationale:
3. What is correct about a nursing diagnosis?
- A. It is a human response to disease, injury, or other stressors.
- B. It remains constant as long as the disease is present.
- C. It is a way to identify pathology.
- D. It is a disease, illness, or injury.
Correct answer: A
Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.
4. 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 as it can lead to blood clots.
5. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?
- A. The client's incision site has eviscerated
- B. The client's incision site has lacerated
- C. The client's incisional site is approximated
- D. The client's incisional site has dehisced after.
Correct answer: A
Rationale:
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