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. While assessing a critically ill client in the emergency department, the nurse notes on the cardiac monitor an R-on-T premature ventricular beat that develops into ventricular tachycardia (VT). Immediately, the client became unresponsive. The nurse knows that based on pathophysiologic principles, the most likely cause of the unresponsiveness is:
- A. metabolic acidosis that occurs spontaneously following any dysrhythmias.
- B. interruption of the blood/oxygen supply to the brain.
- C. massive cerebrovascular accident (CVA) resulting from increased perfusion.
- D. a blood clot coming from the heart and occluding the carotid arteries.
Correct answer: B
Rationale: The correct answer is B. Ventricular tachycardia (VT) can disrupt the normal heart function, leading to a decreased cardiac output. This decreased output can interrupt the blood supply to the brain, causing the client to become unresponsive. Metabolic acidosis (Choice A) is not the most likely cause of unresponsiveness in this scenario. A massive cerebrovascular accident (CVA) (Choice C) would not result from increased perfusion. A blood clot occluding the carotid arteries (Choice D) may lead to a stroke but is not the most likely cause of sudden unresponsiveness in this situation.
3. A healthcare professional is performing hearing screenings for children at a community health fair. Which of the following children should the professional refer to a provider for a more extensive hearing evaluation?
- A. A toddler who is 18 months old and has unintelligible speech
- B. An infant who is 3 months old and has an exaggerated startle response
- C. A preschooler who is 4 years old and prefers playing with others rather than alone
- D. An infant who is 8 months old and is not yet making babbling sounds
Correct answer: D
Rationale: The healthcare professional should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing. Babbling sounds are a developmental milestone that typically occurs by 7 months of age. Delayed or absent babbling can indicate potential hearing issues that warrant further assessment.
4. A client has a new prescription for Furosemide. What instruction should be included by the nurse during discharge?
- A. Take the medication at bedtime.
- B. Increase intake of foods high in potassium.
- C. Avoid sun exposure.
- D. Limit fluid intake.
Correct answer: B
Rationale: The correct answer is to instruct the client to increase intake of foods high in potassium. Furosemide, a loop diuretic, can lead to potassium depletion. Increasing the intake of foods rich in potassium can help prevent hypokalemia, a potential side effect of Furosemide. Choice A is incorrect as Furosemide is usually recommended to be taken in the morning to avoid disrupting sleep with frequent urination. Choice C is irrelevant to the medication. Choice D is also incorrect as Furosemide is a diuretic and may require increased, not limited, fluid intake to prevent dehydration.
5. The home health nurse visits older adult clients at an assisted living center. Which foods should the nurse recommend to correct the main nutrient deficits for this population?
- A. Carbohydrates
- B. Oily fish and krill oil
- C. Yellow vegetables
- D. Dairy products
Correct answer: D
Rationale: The correct answer is D: Dairy products. Older adults are often deficient in calcium and vitamin D, which are abundant in dairy products. These nutrients are essential for maintaining bone health. Choice A (Carbohydrates) is incorrect because while carbohydrates are an essential nutrient, they are not specifically addressing the main nutrient deficits for older adults. Choice B (Oily fish and krill oil) is incorrect as these foods are sources of omega-3 fatty acids and not specifically addressing the main nutrient deficits common in older adults. Choice C (Yellow vegetables) is incorrect because although vegetables are important for overall health, they do not directly address the main nutrient deficits typically seen in older adults.
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