ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?
- A. Ischial tuberosity
- B. Compartment syndrome
- C. Broken arm syndrome
- D. Pulmonary embolism
Correct answer: B
Rationale:
2. A client has a new arm cast. What is incorrect teaching by the nurse?
- A. Use a sling to alleviate fatigue
- B. Elevate the arm above the heart to reduce swelling
- C. Report ‘hot spots’ felt under the cast
- D. Sudden increase in drainage is expected
Correct answer: D
Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
3. A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
- A. Administer glucosamine supplements
- B. Turn the client every 2 hours
- C. Provide active range of motion (ROM)
- D. Provide passive range of motion (ROM)
Correct answer: D
Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.
4. A nurse is caring for an immobile client. What is the priority assessment of this client?
- A. Palpate for edema
- B. Auscultate for bowel sounds
- C. Inspect the skin for injury
- D. Auscultation of lung sounds
Correct answer: C
Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.
5. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
- A. Client will increase mobility by the time of discharge from hospital
- B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
- C. Client will increase activity tolerance by discharge from the hospital
- D. Client will remain free from falls throughout their hospital stay
Correct answer: D
Rationale:
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