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 wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?
- A. Creamy pus
- B. Serous
- C. Serosanguineous
- D. Purulent exudate
Correct answer: C
Rationale:
3. Which of the following assessments is found in neurovascular compromise?
- A. Tingling
- B. Strong pulses
- C. Warm skin
- D. Full range motion
Correct answer: A
Rationale: Tingling is a common sign of neurovascular compromise.
4. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?
- A. The UAP puts shoes on the client
- B. The UAP removes floor rugs and loose objects from the path
- C. The UAP walks to the side and slightly in front of the client
- D. The UAP uses a transfer (gait) belt
Correct answer: C
Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.
5. What health teaching would not help an older adult avoid a musculoskeletal injury?
- A. Avoid home modification
- B. Wear a helmet when riding a bicycle
- C. Osteoporosis screening
- D. Fall prevention
Correct answer: A
Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.
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