ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?
- A. I can spread this through contact with surfaces, so I need to wear gloves in public.'
- B. Because I have HIV, that means I'm an AIDS patient'
- C. I need to ensure that I place my needles in a proper needle disposal container.'
- D. I can still have unprotected intercourse with my partner since he does not have HIV.'
Correct answer: C
Rationale:
2. 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:
3. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?
- A. Administer pain medication
- B. Use proper hand hygiene and strict infection control
- C. Delegate all client personal care to specific unlicensed assistive personnel
- D. Plate the client in contact precautions
Correct answer: B
Rationale:
4. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?
- A. The client reports chronic fatigue
- B. The client has a butterfly rash
- C. Blood pressure of 126/85 mm Hg
- D. Urine output of 20 mL/hour
Correct answer: D
Rationale:
5. 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.
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