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 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.
3. Which of the following lab tests should NOT be used for diagnosing connective tissue diseases?
- A. Rheumatoid factor (RF)
- B. Erythrocyte sedimentation rate (ESR)
- C. Anti-nuclear antibody (ANA)
- D. Thyroid stimulating hormone (TSH)
Correct answer: D
Rationale:
4. A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. What statement by the client indicates a correct understanding of the teaching?
- A. "I should choose red meat instead of poultry."?
- B. "I should avoid eating liver and other organ meats."?
- C. I can drink only white wine."?
- D. "I will need to limit the number of fruit servings each day."?
Correct answer: B
Rationale:
5. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?
- A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
- B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
- C. The UAP carefully empties the indwelling catheter bag
- D. The UAP shows the client how to use the call light
Correct answer: A
Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.
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