ATI RN
Multi Dimensional Care | Final Exam
1. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer a protein-rich diet
- C. Offer the client a bedpan for toileting
- D. Turn the client every 4 hours
Correct answer: A
Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.
2. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?
- A. Amount
- B. Consistency
- C. Heat
- D. Odor
Correct answer: C
Rationale:
3. What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?
- A. Intense cold therapy to the extremities
- B. Encourage ultraviolet (UV) light exposure
- C. Administer topical hydrocortisone
- D. Administer antibiotics
Correct answer: C
Rationale:
4. What is not an inappropriate nursing intervention for psoriasis?
- A. Teach the client how to utilize UV radiation
- B. Apply rubbing alcohol to plaques
- C. Apply corticosteroids as ordered
- D. Urge the client to consider participating in support groups
Correct answer: B
Rationale:
5. What is correct about a nursing diagnosis?
- A. It is a human response to disease, injury, or other stressors.
- B. It remains constant as long as the disease is present.
- C. It is a way to identify pathology.
- D. It is a disease, illness, or injury.
Correct answer: A
Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.
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