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 observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?
- A. The UAP puts shoes on the client
- B. The UAP removes floor rugs and loose objects from the path
- C. The UAP walks to the side and slightly in front of the client
- D. The UAP uses a transfer (gait) belt
Correct answer: C
Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.
3. What is an example of proper body mechanics when lifting?
- A. Lifting the object with your back
- B. Standing with a narrow stance
- C. Lifting excessive weight to strengthen the muscles
- D. Holding the object close to the body
Correct answer: D
Rationale: Proper body mechanics include holding objects close to the body to prevent injury.
4. What statement by the client with plantar fasciitis indicates a need for further teaching?
- A. I will use warm packs on my feet.
- B. I will use nonsteroidal anti-inflammatory drugs (NSAIDS) for comfort.
- C. I will rest and stretch my feet.
- D. I will wear supportive shoes.
Correct answer: A
Rationale: The correct answer is A. Using warm packs can exacerbate inflammation in plantar fasciitis. Choices B, C, and D are all appropriate interventions for managing plantar fasciitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation. Resting and stretching the feet can promote healing and reduce symptoms. Wearing supportive shoes can provide stability and reduce strain on the plantar fascia. Therefore, the client's statement about using warm packs indicates a need for further teaching as it can worsen the condition.
5. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?
- A. The client's incision site has eviscerated
- B. The client's incision site has lacerated
- C. The client's incisional site is approximated
- D. The client's incisional site has dehisced after.
Correct answer: A
Rationale:
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