ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?
- A. Label the specimen tube
- B. Put on non-sterile gloves
- C. Gently remove the soiled dressings
- D. Irrigate the wound
Correct answer: B
Rationale:
2. What evaluation indicates successful progress on the client goal of increasing daily physical activity?
- A. The client reports decreased social interaction
- B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
- C. The client reports a fall
- D. The client reports less fatigue walking up stairs
Correct answer: D
Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.
3. Which nonpharmacological intervention does not help reduce edema?
- A. Heat therapy
- B. Passive range of motion (PROM)
- C. Elevation of the extremity
- D. Cold therapy
Correct answer: A
Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.
4. 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.
5. A client arrives speaking only Spanish. What is the priority nursing intervention?
- A. Give the client a tour of the unit
- B. Verify the reason for admission
- C. Request a medical interpreter
- D. Call the chaplain for support
Correct answer: C
Rationale:
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