ATI RN
Multi Dimensional Care | Final Exam
1. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
2. The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?
- A. Place the bed in the lowest possible position
- B. Use the legs when lifting
- C. Keep feet apart to provide a wide base of support
- D. Face the direction of the movement
Correct answer: A
Rationale: Placing the bed in the lowest possible position increases the risk of injury because it does not support proper body mechanics. When lifting a client, it is important to have the bed at a comfortable height to avoid strain. Using the legs when lifting (choice B) is correct as it reduces the strain on the back. Keeping feet apart to provide a wide base of support (choice C) helps with stability and balance. Facing the direction of the movement (choice D) is essential for maintaining proper alignment and reducing the risk of injury.
3. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?
- A. Collect a culture of the purulent fluid
- B. Cleanse the skin around the pins
- C. Administer an antibiotic
- D. Instruct the client to complete exercise of the affected extremity
Correct answer: A
Rationale:
4. What is an example of a client's primary defense to infection?
- A. Intact skin
- B. Inflammation
- C. Phagocytosis
- D. Fever
Correct answer: A
Rationale:
5. Where will the nurse collect the most reliable source of pain assessment?
- A. From the nurse-to-nurse bedside report
- B. From a medical surgical book
- C. From the client
- D. From the client's chart
Correct answer: C
Rationale:
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