ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?
- A. Mental state
- B. Friction and shear
- C. Nutrition
- D. Sensory perception
Correct answer: A
Rationale:
2. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?
- A. PAPR mask
- B. Sterile gloves
- C. Gown
- D. Surgical mask
Correct answer: C
Rationale:
3. 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:
4. What medication class can decrease tissue inflammation but delays bone healing?
- A. Anticoagulants
- B. Nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Opioids
- D. Narcotics
Correct answer: B
Rationale: The correct answer is B: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to decrease tissue inflammation but may delay bone healing. Anticoagulants (Choice A) are used to prevent blood clotting, opioids (Choice C) are pain relievers, and narcotics (Choice D) are drugs that affect the central nervous system. While all the choices may have their own indications and uses in healthcare, NSAIDs are specifically associated with delaying bone healing despite their anti-inflammatory properties.
5. A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?
- A. Delegate all client personal care to specific unlicensed assistive personnel
- B. Place the client in contact precautions
- C. Proper hand hygiene
- D. Administer pain medication
Correct answer: C
Rationale: Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.
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