ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?
- A. Deliver upward abdominal thrusts with a fisted hand
- B. Perform a blind finger sweep of the child's mouth
- C. Complete five rapid back blows between the shoulder blades
- D. Encourage the child to continue coughing
Correct answer: D
Rationale:
2. 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:
3. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?
- A. Two-point gait
- B. Three-point gait
- C. Four-point gait
- D. Unaffected gait
Correct answer: B
Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.
4. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?
- A. The client reports chronic fatigue
- B. The client has a butterfly rash
- C. Blood pressure of 126/85 mm Hg
- D. Urine output of 20 mL/hour
Correct answer: D
Rationale:
5. What is a symptom of the expected disease pattern of rheumatoid arthritis?
- A. Unilateral joint pain
- B. Bilateral joint pain
- C. Contralateral joint pain
- D. Obtuse variety joint pain
Correct answer: B
Rationale:
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