ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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: “Bleeding and swelling cause increased pressure in an area that cannot expand.”
Rationale:
2. A nurse is providing discharge teaching to a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?
- A. Avoid eating foods that are high in fat.
- B. Monitor for black, tarry stools while taking this medication.
- C. Avoid taking this medication with grapefruit juice.
- D. Take this medication on an empty stomach.
Correct answer: B
Rationale: The correct instruction for the nurse to include is to advise the client to monitor for black, tarry stools while taking clopidogrel. This is important because it helps detect gastrointestinal bleeding, a potential side effect of the medication. Choice A is incorrect as there is no specific requirement to avoid foods high in fat while taking clopidogrel. Choice C is incorrect as grapefruit juice interaction is not a concern with clopidogrel. Choice D is incorrect as clopidogrel can be taken with or without food.
3. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following actions should the provider take?
- A. Insert the needle at a 90-degree angle
- B. Insert the needle at a 45-degree angle
- C. Inject the medication slowly after aspiration
- D. Massage the site after injection
Correct answer: A
Rationale: Correct answer: When administering an intramuscular injection, the needle should be inserted at a 90-degree angle to ensure proper delivery of the medication into the muscle tissue. Option B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Option C is incorrect as aspiration is not recommended for intramuscular injections. Option D is incorrect as massaging the site after an intramuscular injection can cause tissue damage or interfere with the absorption of the medication.
4. In a disaster where a building has collapsed, which victim should a nurse attend to first?
- A. A victim who has died of multiple serious injuries
- B. A victim with a partial amputation of a leg who is bleeding profusely
- C. An alert victim who has numerous bruises on the arms and legs
- D. A hysterical victim who has sustained a head injury
Correct answer: B
Rationale: In a disaster situation like a building collapse, the nurse should attend to the victim with a partial amputation of a leg who is bleeding profusely first. This victim is at immediate risk of severe blood loss, which can be life-threatening. It is crucial to address life-threatening injuries like severe bleeding before attending to other less urgent cases. The victim with the amputation requires immediate intervention to control bleeding and stabilize their condition. Victims who are already deceased or have less urgent injuries can be attended to after addressing the critical cases.
5. Cellular swelling is:
- A. Irreversible
- B. Evident early in all types of cellular injury
- C. Manifested by decreased intracellular sodium
- D. None of the above is correct
Correct answer: B
Rationale: Cellular swelling is indeed evident early in all types of cellular injury. This occurs due to the influx of water into the cell, leading to swelling. Choice A is incorrect because cellular swelling is reversible if the injury is not severe. Choice C is incorrect because cellular swelling is not manifested by decreased intracellular sodium; in fact, it is associated with increased intracellular sodium due to water influx. Choice D is incorrect as option B is the correct statement.
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