ATI RN
Multi Dimensional Care | Final Exam
1. What should be done immediately after an ankle injury?
- A. Immobilize, heat, compress, and elevate the ankle
- B. Rest, ice, compress, and lower the ankle
- C. Rest, ice, compress, and elevate the ankle
- D. Rest, incubate, confine, and lower the ankle
Correct answer: C
Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.
2. By providing measures to reduce skin breakdown, how does the nurse break the chain of infection?
- A. Sterilizing the area to reduce the reservoir risk
- B. Maintaining the integrity of a portal of entry
- C. Creating a reservoir to decrease the risk of infection
- D. Creating a susceptible host
Correct answer: B
Rationale:
3. Why is traction used?
- A. It allows the bones to realign
- B. It decreases the risk of misalignment
- C. It promotes wound healing
- D. It allows the client to rest longer
Correct answer: A
Rationale: Traction is used to help align the bones properly during the healing process. Choice A is correct because traction assists in allowing the bones to realign correctly, promoting proper healing. Choice B is incorrect as traction does not decrease the risk of misalignment; instead, it helps reduce misalignment by aiding in bone alignment. Choice C is incorrect because while traction indirectly supports wound healing by ensuring proper bone alignment, its primary purpose is not wound healing. Choice D is incorrect as the primary purpose of traction is not to allow the client to rest longer, but rather to aid in bone alignment for optimal healing.
4. What is one of the earliest signs of fat embolism syndrome?
- A. Paresthesia
- B. Severe pain in the affected limb unrelieved by medication
- C. Edema
- D. Hypoxemia
Correct answer: D
Rationale: Hypoxemia is one of the earliest signs of fat embolism syndrome. In fat embolism syndrome, fat globules enter the bloodstream and can obstruct blood flow in the lungs, leading to hypoxemia. Paresthesia, severe pain unrelieved by medication, and edema are not typically among the earliest signs of fat embolism syndrome.
5. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
- A. Use a mechanical lift to reposition the client every 2 hours
- B. Elevate the client's head of the bed to 45 degrees
- C. Postpone daily bed bath
- D. Caregiver independently slides the client up in the bed
Correct answer: A
Rationale:
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