ATI RN
Multi Dimensional Care | Final Exam
1. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?
- A. 15 degrees
- B. 0 degrees
- C. 90 degrees
- D. 30 degrees
Correct answer: C
Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.
2. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
- A. The nurse assesses capillary refill of 2 seconds
- B. The nurse cannot insert one finger between the cast and the skin
- C. The nurse finds 2+ pulses distal from the cast
- D. The nurse does not observe any drainage
Correct answer: B
Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.
3. The client states, “the doctor says I am nearsighted. I do not get it.†What would be the best response by the nurse?
- A. I am sorry you did not understand. Would you like a different doctor?
- B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
- C. You will need to have glasses.
- D. This means you won’t ever need glasses.
Correct answer: B
Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.
4. What statement by the client with plantar fasciitis indicates a need for further teaching?
- A. I will use warm packs on my feet.
- B. I will use nonsteroidal anti-inflammatory drugs (NSAIDS) for comfort.
- C. I will rest and stretch my feet.
- D. I will wear supportive shoes.
Correct answer: A
Rationale: The correct answer is A. Using warm packs can exacerbate inflammation in plantar fasciitis. Choices B, C, and D are all appropriate interventions for managing plantar fasciitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation. Resting and stretching the feet can promote healing and reduce symptoms. Wearing supportive shoes can provide stability and reduce strain on the plantar fascia. Therefore, the client's statement about using warm packs indicates a need for further teaching as it can worsen the condition.
5. A client has AIDS. Which of these findings indicate possible infection?
- A. Respirations; 22 breaths per minute
- B. Client ambulates 20 feet
- C. Purulent drainage
- D. Oxygen saturation; 97% on room air
Correct answer: C
Rationale:
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