ATI RN
Multi Dimensional Care | Final Exam
1. What health teaching would not help an older adult avoid a musculoskeletal injury?
- A. Avoid home modification
- B. Wear a helmet when riding a bicycle
- C. Osteoporosis screening
- D. Fall prevention
Correct answer: A
Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.
2. What is the best goal for pain control in a client with RA?
- A. The client will eat healthy meals today and stay hydrated
- B. The client will have throughout the entire day
- C. The client will have pain less than 3/10 for most of the day
- D. The client will have pain less than 8/10 throughout the day
Correct answer: D
Rationale:
3. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?
- A. Label the specimen tube
- B. Put on non-sterile gloves
- C. Gently remove the soiled dressings
- D. Irrigate the wound
Correct answer: B
Rationale:
4. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present
Correct answer: D
Rationale:
5. 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.
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