ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
A client has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?
Correct Answer: A
Rationale: The correct answer is A) Primary intention. Primary intention healing occurs when a wound is clean, well-approximated, and closed with sutures, like in the case of the abdominal incision closed with 10 sutures. This type of healing leads to minimal scar formation and faster recovery due to the edges of the wound being closely aligned, promoting efficient healing through the formation of granulation tissue. Option B) Binary intention is not a recognized term in wound healing. Secondary intention, option C), is a different process where a wound is left open to heal from the base up, often resulting in more significant scarring and a longer healing time due to the need for tissue regeneration. Understanding the different types of wound healing processes is crucial for healthcare professionals as it helps in determining appropriate wound care techniques, monitoring for signs of complications, and setting realistic expectations for the healing process with patients. This knowledge is vital in providing optimal care and promoting positive outcomes for patients undergoing surgical procedures.
Question 2 of 5
A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?
Correct Answer: C
Rationale: In the context of admitting a client with tuberculosis, the appropriate transmission-based precautions that the nurse should initiate are airborne precautions. Tuberculosis is primarily spread through the air when an infected individual coughs, sneezes, or talks, releasing droplet nuclei containing the bacteria. Airborne precautions are necessary to prevent the transmission of these infectious droplet nuclei to others. Option A, droplet precautions, are used for diseases that are transmitted through large respiratory droplets that do not remain suspended in the air for long periods, like influenza. Contact precautions (Option B) are used for diseases that are spread by direct or indirect contact with the patient or their environment, such as MRSA. Protective precautions (Option D) are not a standard transmission-based precaution category. Educationally, understanding the rationale behind selecting the correct transmission-based precautions for specific infectious diseases is crucial for nurses to provide safe and effective care, prevent the spread of infections within healthcare settings, and protect both patients and healthcare workers. By knowing the modes of transmission and appropriate precautions for different diseases, nurses can play a key role in infection control and maintaining a safe healthcare environment.
Question 3 of 5
The nurse is caring for 4 clients. Which of these clients will the nurse see first?
Correct Answer: A
Rationale: In this scenario, the nurse should prioritize client safety and urgent needs. Option A, a client with sudden and increasing pain in a fractured arm, should be seen first. This client's condition requires immediate attention to assess for complications like compartment syndrome. Option B, a client needing crutch teaching before discharge, is important but can wait as it is not immediately life-threatening. Option C, a client with RA and scheduled pain medication, has a planned intervention and is not in acute distress. Option D, a client with a fractured ankle requesting water, has a relatively lower priority compared to the client in severe pain. Educationally, this question highlights the significance of prioritizing care based on client needs. It reinforces the concept of triaging and addressing urgent issues promptly in a clinical setting to ensure optimal patient outcomes. Nurses must be able to differentiate between urgent, important, and routine tasks to provide safe and effective care.
Question 4 of 5
The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
Correct Answer: D
Rationale: In this scenario, the nurse should choose option D, which is to keep the nursing diagnosis in the plan of care the same since the risk factors are still present. This is the best action because even though the skin integrity has not been impaired after one week, the client is still at risk due to the continued need for bedrest. Choosing option A to remove the nursing diagnosis is incorrect because the risk factors that led to the initial diagnosis are still present, so vigilance is necessary. Option B, changing the diagnosis to impaired mobility, is not appropriate as the primary concern is the risk of impaired skin integrity due to prolonged bedrest. Option C, modifying the diagnosis to impaired skin integrity, is unnecessary since the skin integrity has not been compromised yet, but the risk remains. Educationally, this scenario highlights the importance of ongoing assessment and evaluation in nursing care. It emphasizes the need to consider the underlying risk factors that led to the initial diagnosis and to continue monitoring the client's condition to provide proactive care and prevent potential complications. It also underscores the significance of critical thinking and clinical judgment in nursing practice.
Question 5 of 5
Which among the following is NOT the cause of pressure ulcers?
Correct Answer: D
Rationale: In understanding the causes of pressure ulcers, it is crucial to recognize the role of perfusion in preventing these skin injuries. Adequate perfusion, which refers to the circulation of blood to tissues, is essential for maintaining the health of the skin and preventing the development of pressure ulcers. When tissues do not receive enough blood flow, they are more susceptible to damage from prolonged pressure, leading to the formation of pressure ulcers. Immobility, poor nutrition, and moisture are all well-established risk factors for pressure ulcers. Immobility can result in prolonged pressure on certain areas of the body, reducing blood flow and causing tissue damage. Poor nutrition can impair the body's ability to repair and maintain healthy skin, making individuals more vulnerable to pressure ulcers. Moisture, especially when combined with pressure, can further increase the risk of skin breakdown and ulcer formation. In an educational context, understanding the causes of pressure ulcers is essential for healthcare professionals, caregivers, and patients themselves. By recognizing the significance of factors such as immobility, poor nutrition, moisture, and perfusion, individuals can implement preventive measures to reduce the incidence of pressure ulcers. Educating patients on the importance of mobility, proper nutrition, skin care, and circulation can empower them to take proactive steps in maintaining skin integrity and overall well-being.