ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?
- A. An adolescent who has a patella fracture and is in an immobilizer
- B. A young adult who has a femur fracture and is going to surgery in two hours
- C. A middle-aged adult who has fractured his radius and has a cast
- D. An older adult who has a hip fracture and is immobile
Correct answer: D
Rationale:
2. A nurse is caring for an immobile client. What is the priority assessment in this client?
- A. Auscultation of lung sounds
- B. Assessment of skin turgor
- C. Auscultation of bowel sounds
- D. Assessment for the presence of peripheral edema
Correct answer: A
Rationale:
3. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?
- A. Collect a culture of the purulent fluid
- B. Cleanse the skin around the pins
- C. Administer an antibiotic
- D. Instruct the client to complete exercise of the affected extremity
Correct answer: A
Rationale:
4. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?
- A. Because it is easy to digest.'
- B. Protein has amin acid that promotes wound healing.'
- C. If you do not like it, you do not have to take it.'
- D. These supplements have nothing to do with your wound,'
Correct answer: B
Rationale:
5. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?
- A. Once bacterial infection has caused damage, the tissue does not regenerate.
- B. Once retinal detachment occurs, it does not return to its normal state.
- C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
- D. Glaucoma always leads to permanent blindness.
Correct answer: C
Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.
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