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 nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?
- A. Intense cold therapy to the extremities
- B. Encourage ultraviolet (UV) light exposure
- C. Administer topical hydrocortisone
- D. Administer antibiotics
Correct answer: C
Rationale:
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. What is a sign of inadequate perfusion?
- A. Intact sensation
- B. Pallor in toes
- C. Bounding pulses
- D. Pink fingers
Correct answer: B
Rationale:
5. A nurse assesses an area of skin over a bony prominence. What finding would be most concerning?
- A. Redness
- B. Non-blanching
- C. Blanching
- D. Warmth
Correct answer: A
Rationale:
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