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 client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
- A. Assess the right radial pulse
- B. Call the provider
- C. Administer pain medication
- D. Assess the right pedal pulse
Correct answer: A
Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.
3. What soft tissue musculoskeletal injury is excessive stretching of a ligament?
- A. Sprain
- B. Ligament tear
- C. Strain
- D. Tendon rupture
Correct answer: A
Rationale: A sprain is an injury involving excessive stretching of a ligament.
4. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
5. What is the best goal for pain control in a client with RA?
- A. The client will eat healthy meals today and stay hydrated
- B. The client will have throughout the entire day
- C. The client will have pain less than 3/10 for most of the day
- D. The client will have pain less than 8/10 throughout the day
Correct answer: D
Rationale:
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