ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?
- A. Offer the client protein with meals to promote healing
- B. Remove the old dressing with clean gloves
- C. Teach the client about nonpharmacological pain control methods
- D. Check medication administration record (MAR)for as needed orders (PRN)
Correct answer: C
Rationale:
2. What is the best nursing intervention for a client with limited mobility who cannot move independently?
- A. Passive range of motion
- B. Pillows for positioning
- C. Active range of motion
- D. Continuous passive motion
Correct answer: A
Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.
3. The client with rheumatoid arthritis is having her rheumatoid factor (RF) drawn while she is having a flare-up of the disease. Which result is seen in clients with rheumatoid arthritis?
- A. Factor does not change
- B. Decreased level of rheumatoid arthritis
- C. A positive rheumatoid factor
- D. A negative rheumatoid factor
Correct answer: C
Rationale:
4. What is the nurse's priority action for a client with compromised immunity?
- A. Wash hands before entering the client's room
- B. Take the client's vital signs every 4 hours
- C. Determine whether it is temporary or permanent
- D. Teach the family members to receive the flu shot annually
Correct answer: A
Rationale:
5. What are signs of hearing loss? (Select all that apply)
- A. Answering questions correctly
- B. Presence of cerumen
- C. Tinnitus
- D. Frequent asking of others to repeat statements
Correct answer: C
Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.
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