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: Mental state
Rationale:
2. A nurse is assigned to care for a client with unstable blood pressure. What should the nurse do first?
- A. Monitor the client every two hours.
- B. Continuously monitor the client's vital signs.
- C. Wait for the healthcare provider to provide instructions.
- D. Ask the healthcare provider for specific instructions.
Correct answer: B
Rationale: In the case of a client with unstable blood pressure, the priority action for the nurse is to continuously monitor the client's vital signs. This allows for immediate detection of any fluctuations in blood pressure and timely intervention if necessary. Choice A, monitoring every two hours, may not provide real-time information needed for prompt intervention. Choices C and D suggest waiting for instructions from the healthcare provider, which could cause a delay in addressing the unstable blood pressure, potentially leading to adverse outcomes. Therefore, the most appropriate initial action is to continuously monitor the client's vital signs.
3. A client has a chest tube. Which of the following interventions should the nurse include?
- A. Clamp the chest tube for 15 minutes every 2 hours.
- B. Maintain the drainage system below the client's chest.
- C. Strip the chest tube every 2 hours.
- D. Keep the collection device at the level of the client's chest.
Correct answer: B
Rationale: Maintaining the chest tube drainage system below the client's chest level is crucial to ensure proper drainage and prevent complications. Clamping the chest tube can lead to a tension pneumothorax, stripping the chest tube is an outdated practice that can cause damage to the tissues, and keeping the collection device at the level of the client's chest can impede proper drainage and lead to fluid accumulation.
4. Which statement by a client indicates a need for further teaching about food safety?
- A. I will use the food before the expiration date listed on the package.
- B. I will wash my strawberries before I eat them.
- C. I will drink unpasteurized milk as it has many gut-healthy probiotics.
- D. I will wash my hands after I prepare raw chicken.
Correct answer: C
Rationale: The correct answer is C because drinking unpasteurized milk can contain harmful bacteria, which poses a risk to food safety. Choice A is correct as it emphasizes using food before the expiration date. Choice B is also correct as washing fruits before consumption is a good food safety practice. Choice D is correct as well since washing hands after handling raw chicken is crucial to prevent cross-contamination. Therefore, choice C is the only statement that indicates a need for further teaching on food safety.
5. Which of the following drugs is associated with extreme photosensitivity as a reaction?
- A. Digitalis
- B. Niacin
- C. Tetracycline
- D. Fluoroquinolones
Correct answer: C
Rationale: Tetracycline is known to cause extreme photosensitivity reactions, making individuals more sensitive to sunlight and increasing the risk of severe sunburn. It is essential for patients taking tetracycline to protect themselves from excessive sun exposure to prevent adverse reactions.
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