ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?
- A. Diagnosis
- B. Assessment
- C. Implementation
- D. Evaluation
Correct answer: B
Rationale:
2. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?
- A. Applying moisturizer to dry areas of the skin
- B. Massaging the client's reddened shoulders and heels
- C. Cleansing the skin routinely after soiling occurs
- D. Using a Hoyer lift for all transfers
Correct answer: B
Rationale:
3. The client had surgery one day ago. What assessment is most likely related to pain?
- A. Blood pressure of 175/90 mm Hg
- B. Respirations of 10 breaths per minute
- C. Heart rate 60 beats/minute
- D. Oxygen saturation of 97%
Correct answer: A
Rationale:
4. What are some of the expected outcomes when medications are given for rheumatoid arthritis?
- A. Increased quality of life
- B. Increased range of motion
- C. Decreased pain
- D. Cure the disease
Correct answer: C
Rationale:
5. What should be done immediately after an ankle injury?
- A. Immobilize, heat, compress, and elevate the ankle
- B. Rest, ice, compress, and lower the ankle
- C. Rest, ice, compress, and elevate the ankle
- D. Rest, incubate, confine, and lower the ankle
Correct answer: C
Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.
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