ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Which of the following nonpharmacological methods cannot be used to manage the chronic pain of a client with rheumatoid arthritis?
- A. Adequate rest
- B. Heat for 20-30 minutes
- C. Hot showers
- D. Ice for 2 hours at a time
Correct answer: D
Rationale:
2. 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: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.
3. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?
- A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
- B. "An injured artery causes impaired arterial perfusion through the compartment."?
- C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
- D. . "A bone fragment has injured the nerve supply in the area."?
Correct answer: C
Rationale:
4. What are signs of hearing loss? (Select all that apply)
- A. Answering questions correctly
- B. Presence of cerumen
- C. Tinnitus
- D. Frequent asking of others to repeat statements
Correct answer: C
Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.
5. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct answer: D
Rationale:
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