ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?
- A. Tunnelling
- B. Eschar
- C. Blanching
- D. Cellulitis
Correct answer: B
Rationale:
2. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
- A. The nurse assesses capillary refill of 2 seconds
- B. The nurse cannot insert one finger between the cast and the skin
- C. The nurse finds 2+ pulses distal from the cast
- D. The nurse does not observe any drainage
Correct answer: B
Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.
3. What is not a potential complication of RA?
- A. Paresthesia's
- B. Fibromyalgia
- C. Joint deformity
- D. Dry eyes
Correct answer: A
Rationale:
4. 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: The orthopneic position helps improve lung expansion, reducing the risk of atelectasis.
5. What steps are NOT included in preparing a sterile field?
- A. Do not turn away from the sterile field
- B. Obtain PAPR mask
- C. Prepare the client before setting up the sterile field
- D. Cover the sterile field once it is set up
Correct answer: B
Rationale:
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