ATI RN
Multi Dimensional Care | Final Exam
1. A nurse is caring for an immobile client. What is the priority assessment of this client?
- A. Palpate for edema
- B. Auscultate for bowel sounds
- C. Inspect the skin for injury
- D. Auscultation of lung sounds
Correct answer: C
Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.
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. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?
- A. Observe client for changes in mental status
- B. Use aseptic technique for wound care and emptying of drains
- C. Keep the client's heels off the bed
- D. Perform neurovascular assessments per protocol
Correct answer: D
Rationale:
4. What is an example of a client's primary defense to infection?
- A. Intact skin
- B. Inflammation
- C. Phagocytosis
- D. Fever
Correct answer: A
Rationale:
5. A client has a new arm cast. What is incorrect teaching by the nurse?
- A. Use a sling to alleviate fatigue
- B. Elevate the arm above the heart to reduce swelling
- C. Report ‘hot spots’ felt under the cast
- D. Sudden increase in drainage is expected
Correct answer: D
Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
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