ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?
- A. Intense cold therapy to the extremities
- B. Encourage ultraviolet (UV) light exposure
- C. Administer topical hydrocortisone
- D. Administer antibiotics
Correct answer: C
Rationale:
2. 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.
3. The following client come to the ophthalmology clinic. Which client needs to be seen first?
- A. Client who had recent cataract surgery and has worsening vision
- B. Client with an absent red reflex on ophthalmic examination
- C. Client with an intraocular pressure of 24 mm Hg
- D. Client with a tearing, reddened eye with exudate
Correct answer: A
Rationale: Worsening vision after cataract surgery requires immediate attention to prevent complications.
4. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?
- A. The client sets the cap down in a manner that does not contaminate it.
- B. The client drops the prescribed number of drops into the conjunctival sac
- C. The client washes their hands before instilling the drops
- D. The client ensures that they touch the administration dropper to the eye
Correct answer: D
Rationale: Touching the dropper to the eye contaminates it and can lead to infection.
5. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer a protein rich diet
- C. Offer the client a bedpan for toileting
- D. Turn the client every 4 hours
Correct answer: A
Rationale: The orthopneic position helps improve lung expansion, reducing the risk of atelectasis.
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