ATI RN
Multi Dimensional Care | Final Exam
1. 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.
2. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?
- A. The client sets the cap down in a manner that does not contaminate it.
- B. The client drops the prescribed number of drops into the conjunctival sac
- C. The client washes their hands before instilling the drops
- D. The client ensures that they touch the administration dropper to the eye
Correct answer: D
Rationale: Touching the dropper to the eye contaminates it and can lead to infection.
3. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?
- A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
- B. "An injured artery causes impaired arterial perfusion through the compartment."?
- C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
- D. . "A bone fragment has injured the nerve supply in the area."?
Correct answer: C
Rationale:
4. What activities should the client avoid after cataract surgery? (Select all that apply)
- A. Blowing one’s nose
- B. Bearing down during defecation
- C. Lifting items heavier than 10 pounds
- D. All of the Above
Correct answer: D
Rationale: After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one’s nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.
5. Which of the following statements made by a client diagnosed with human immunodefiency virus (HIV) would require further teaching?
- A. "I will have to be careful and avoid crowds."?
- B. "I will take prescribed medications."?
- C. "I will have to take medications for the rest of my life."?
- D. "I will only need to take HIV medications for 6 months, and I will be cured
Correct answer: D
Rationale:
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