ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
A client has AIDS. Which of these findings indicate possible infection?
Correct Answer: C
Rationale: In this scenario, option C, purulent drainage, is the correct answer indicating a possible infection in a client with AIDS. Purulent drainage is a sign of infection as it represents the presence of pus, which is a result of the body's immune response to an infection. In clients with AIDS, who have compromised immune systems, any signs of infection should be taken seriously and addressed promptly. Option A, respirations at 22 breaths per minute, is a normal respiratory rate and does not specifically indicate infection. Option B, client ambulating 20 feet, is a measure of mobility and does not directly relate to the presence of infection. Option D, oxygen saturation at 97% on room air, is within normal range and does not necessarily point towards infection. Educationally, it is crucial for healthcare providers to be able to recognize signs of infection in clients with AIDS due to their increased susceptibility to infections. Understanding these signs can assist in early detection and prompt treatment, which is vital in managing the health of clients with compromised immune systems.
Question 2 of 5
What steps are NOT included in preparing a sterile field?
Correct Answer: B
Rationale: In the context of healthcare, preparing a sterile field is a critical step to prevent the spread of infection during medical procedures. The correct answer, B) Obtain PAPR mask, is the step NOT included in preparing a sterile field. Explanation: A) "Do not turn away from the sterile field" is important to maintain the integrity of the sterile area by avoiding contamination. C) "Prepare the client before setting up the sterile field" is essential to ensure the client is ready for the procedure but is not directly related to the sterile field setup. D) "Cover the sterile field once it is set up" is crucial to maintain the sterility of the field until the procedure begins. Educational Context: Understanding the steps involved in preparing a sterile field is fundamental for healthcare professionals to ensure patient safety and prevent infections. By excluding the step of obtaining a PAPR mask, which is not directly related to setting up the sterile field, this question emphasizes the importance of meticulous attention to detail in maintaining a sterile environment in healthcare settings.
Question 3 of 5
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?
Correct Answer: C
Rationale: The correct answer is C) "Bleeding and swelling cause increased pressure in an area that cannot expand." Compartment syndrome occurs when there is increased pressure within a closed muscle compartment, leading to decreased blood flow, which can result in tissue damage. In the case of a severely fractured arm, bleeding and swelling can accumulate within the compartment, causing pressure to build up. Option A is incorrect because it describes fascial expansion, which is not the primary cause of compartment syndrome. Option B is incorrect as impaired arterial perfusion is a consequence rather than a cause of compartment syndrome. Option D is incorrect as nerve injury is not the main mechanism behind compartment syndrome. Educationally, understanding the pathophysiology of compartment syndrome is crucial for nurses caring for patients with traumatic injuries. By grasping how bleeding and swelling lead to increased pressure within muscle compartments, nurses can promptly recognize and intervene in cases of compartment syndrome to prevent further tissue damage and complications. This knowledge is vital in providing optimal care and improving patient outcomes in orthopedic and trauma settings.
Question 4 of 5
The nurse is caring for 4 clients. What client should the nurse see first?
Correct Answer: C
Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.
Question 5 of 5
A client has suffered from a femur fracture. What is the nurse's priority assessment?
Correct Answer: C
Rationale: In the scenario of a client with a femur fracture, the nurse's priority assessment should be checking the pedal pulses (Option C). This is crucial to evaluate the perfusion and circulation to the lower extremities, especially in the case of a femur fracture where there is a risk of impaired blood flow due to trauma or associated injuries. Without adequate blood flow, the client may be at risk for complications like ischemia or compartment syndrome, which could lead to further damage or even amputation. Option A, pain assessment, is important but would typically come after ensuring adequate circulation and perfusion to the extremity. Pain can be managed once the client's circulation status is stable. Option B, medication history, while relevant for overall care, is not the immediate priority in this situation where assessing perfusion and circulation takes precedence. Option D, socio-economic status, is not directly related to the immediate assessment needed for a client with a femur fracture. While social factors are important in holistic care, they do not take precedence over the client's physiological needs in this acute situation. Educationally, understanding the rationale behind prioritizing assessments based on the client's condition is crucial for nurses to provide safe and effective care. It highlights the importance of critical thinking and clinical judgment in prioritizing interventions to address the most life-threatening issues first.