ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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:
2. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?
- A. Deeply palpate the area for rebound tenderness
- B. Medicate the client for pain and reassess in 60 minutes
- C. Percuss over the area for a change in tone
- D. Compare the circumference to the left calf
Correct answer: D
Rationale:
3. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?
- A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
- B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
- C. The UAP carefully empties the indwelling catheter bag
- D. The UAP shows the client how to use the call light
Correct answer: A
Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.
4. What is the likely reason that a client with acquired immunodeficiency syndrome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not?
- A. The client with AIDS is a susceptible host
- B. The client with AIDS has greater immune defenses
- C. The client with AIDS was not as careful
- D. The client with AIDS has more portals of entry
Correct answer: A
Rationale:
5. The nurse is caring for 4 clients. What client should the nurse see first?
- A. A client with multiple children visiting
- B. A client with lupus asking for dinner
- C. A client on Methotrexate with a fever
- D. A client with chronic rheumatic pain
Correct answer: C
Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.
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