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. What statement by the client with plantar fasciitis indicates a need for further teaching?
- A. I will use warm packs on my feet.
- B. I will use nonsteroidal anti-inflammatory drugs (NSAIDS) for comfort.
- C. I will rest and stretch my feet.
- D. I will wear supportive shoes.
Correct answer: A
Rationale: The correct answer is A. Using warm packs can exacerbate inflammation in plantar fasciitis. Choices B, C, and D are all appropriate interventions for managing plantar fasciitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation. Resting and stretching the feet can promote healing and reduce symptoms. Wearing supportive shoes can provide stability and reduce strain on the plantar fascia. Therefore, the client's statement about using warm packs indicates a need for further teaching as it can worsen the condition.
3. A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective
Correct answer: C
Rationale:
4. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?
- A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
- B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
- C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
- D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?
Correct answer: B
Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.
5. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?
- A. Insert the wound and assess the drainage
- B. Apply topical ointment to the wound
- C. Call the provider to initiate antibiotics
- D. Culture the wound
Correct answer: D
Rationale:
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