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. The following client come to the ophthalmology clinic. Which client needs to be seen first?
- A. Client who had recent cataract surgery and has worsening vision
- B. Client with an absent red reflex on ophthalmic examination
- C. Client with an intraocular pressure of 24 mm Hg
- D. Client with a tearing, reddened eye with exudate
Correct answer: A
Rationale: Worsening vision after cataract surgery requires immediate attention to prevent complications.
3. On inspection, which client does the nurse suspect of having a visual impairment?
- A. The client whose sclera is white
- B. The client who has an intact blink reflex
- C. The client who is tilting their head
- D. The client with equal pupils
Correct answer: C
Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.
4. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?
- A. Encouraging bedrest
- B. Applying antiembolism stockings
- C. Tell the client to take anticoagulants
- D. Teaching about smoking cessation
Correct answer: B
Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.
5. What is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV)?
- A. A few missed doses per month are acceptable
- B. Only specific licensed drugs are effective
- C. These drugs inhibit viral replication
- D. These drugs eradicate the virus
Correct answer: C
Rationale: The correct answer is that antiretroviral drugs inhibit viral replication. These medications work by interfering with the ability of the HIV virus to multiply in the body, helping to control the infection. Choice A is incorrect because consistency in taking antiretroviral drugs is crucial to their effectiveness. Missing doses can lead to treatment failure and the development of drug-resistant strains of HIV. Choice B is incorrect as there are multiple licensed drugs that are effective in treating HIV. Choice D is also incorrect as antiretroviral drugs do not kill the virus but rather suppress its replication.
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