ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What nursing interventions increase the risk the pressure injuries?
- A. Padding hard surfaces
- B. Have client sit in wheelchair as much as possible
- C. Place pillows between bony surfaces
- D. Keep head of bed (HOB) at or less than 3
Correct answer: B
Rationale:
2. A nurse is providing teaching to an older client who has osteoarthritis that is affecting the knees. What statement by the client indicates a correct understanding of the teaching?
- A. I can use either heat or ice to help relieve the discomfort
- B. The purpose of drug therapy is to stop the disease progression.'
- C. I will start a daily running program to get more exercise.'
- D. I should avoid physical activity to prevent further injury.'
Correct answer: A
Rationale:
3. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
- A. Assess the right radial pulse
- B. Call the provider
- C. Administer pain medication
- D. Assess the right pedal pulse
Correct answer: A
Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.
4. 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.
5. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?
- A. Encouraging bedrest
- B. Applying antiembolism stockings
- C. Tell the client to take anticoagulants
- D. Teaching about smoking cessation
Correct answer: B
Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.
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