ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?
Correct Answer: D
Rationale: The correct answer is D) Stage 2. This wound assessment describes a stage 2 pressure ulcer, which is characterized by a shallow, open ulcer with a reddened base but no slough. In stage 2, the damage extends through the epidermis and into the dermis, presenting as a partial-thickness loss of skin. This stage requires appropriate wound care and monitoring to prevent further complications. Option A) Stage 3 is incorrect because in stage 3, the ulcer extends into the subcutaneous tissue, presenting as a full-thickness wound with possible slough but not through muscle or bone. Option B) Stage 4 is incorrect as stage 4 ulcers involve full-thickness skin loss with extensive tissue damage, potentially reaching muscle or bone. Option C) Stage 1 is incorrect because in stage 1, the skin is intact but may show non-blanchable redness, indicating a risk of pressure injury but not a full ulcer. Understanding wound staging is crucial for nurses to provide appropriate care, prevent complications, and promote healing. Nurses must accurately assess and document wounds to guide treatment decisions and prevent progression to more severe stages. Knowledge of wound staging also helps in communicating effectively with the healthcare team and ensuring consistent care practices.
Question 2 of 5
A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
Correct Answer: A
Rationale: In the scenario of providing oral hygiene for an unconscious client, the priority nursing intervention of positioning the client on one side with the head turned towards you is crucial. This position helps prevent aspiration and facilitates drainage of oral secretions, reducing the risk of choking or aspiration pneumonia. Option B, handling dentures with care, is important but not the priority when compared to ensuring proper positioning for a client who is unconscious. Option C, using gentle techniques for fragile mucosa, is also important but falls secondary to the immediate need for positioning. Option D, having a suction apparatus ready, is essential but should come after ensuring proper positioning to maintain the airway. In an educational context, this question emphasizes the critical thinking skills required in prioritizing nursing interventions based on the client's condition. Understanding the rationale behind each option helps students grasp the importance of assessing and addressing the most urgent needs first to ensure patient safety and well-being.
Question 3 of 5
A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to take next is to choose option B) Raise the arm above the level of the heart. The client is showing signs of impaired circulation distal to the cast, indicated by pale, cool, and swollen fingers. Elevating the arm above heart level helps reduce swelling and improve blood flow to the affected area. This position promotes venous return and can alleviate symptoms of compromised circulation. Option A) Removing the cast may not be necessary at this point as there is no increase in pain reported. Removing the cast without medical guidance can potentially worsen the client's condition. Option C) Applying heat to the affected hand is contraindicated in this situation as it can vasodilate blood vessels, potentially exacerbating swelling and compromising circulation further. Option D) Encouraging range of motion is not the priority in this case as the primary concern is addressing the compromised circulation. Range of motion exercises can be beneficial once the circulation issue has been resolved. From an educational perspective, understanding the rationale behind elevating the arm above heart level in cases of compromised circulation is crucial for nurses. It helps them make informed clinical decisions to promote optimal client outcomes and prevent complications related to impaired circulation.
Question 4 of 5
The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?
Correct Answer: A
Rationale: The most appropriate response by the nurse is option A) "Ice packs can be used to reduce swelling but should be removed after 20 minutes." This is the correct answer because ice packs are recommended for reducing inflammation and swelling in rheumatoid arthritis. The application of ice helps constrict blood vessels, reduce inflammation, and numb the area, providing pain relief. However, leaving ice packs on for too long can lead to tissue damage or skin irritation, hence the instruction to remove them after 20 minutes. Option B is incorrect because while heat can help with pain relief, it is not recommended for reducing swelling in rheumatoid arthritis. Heat can actually exacerbate inflammation in this condition. Option C is incorrect because high impact exercises like running can worsen joint pain and inflammation in rheumatoid arthritis. Low-impact exercises are generally recommended to maintain joint mobility without causing further damage. Option D is incorrect because leaving ice packs on for up to one hour can lead to adverse effects such as frostbite or skin damage. It is important to follow the recommended guidelines for using ice packs to avoid complications. In an educational context, it is crucial for nurses to understand the appropriate nonpharmacological interventions for managing rheumatoid arthritis symptoms. Providing accurate information to clients can help improve their quality of life and promote effective self-management of their condition. Nurses play a key role in educating clients about the safe and effective use of interventions like ice packs to alleviate pain and swelling associated with rheumatoid arthritis.
Question 5 of 5
A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Elementary school teacher, as this occupation involves a significant amount of repetitive hand movements such as writing on the board, grading papers, and using a computer, all of which can increase the risk of developing carpal tunnel syndrome due to the continuous strain on the wrist and hand muscles. Option B) Nursing assistant involves tasks that also require repetitive movements, but typically not to the same extent as an elementary school teacher, thus making it a less likely choice for increasing the risk of carpal tunnel syndrome. Option C) Assembly line worker is a physically demanding job that may involve repetitive motions, but carpal tunnel syndrome is more commonly associated with occupations that involve fine motor skills and prolonged use of the hands in specific positions, which is less common in assembly line work. Option D) Truck driver, while requiring long hours of driving, does not typically involve the same level of repetitive hand and wrist movements as the other options mentioned, making it less likely to increase the risk of carpal tunnel syndrome. Educationally, it's important for healthcare professionals to understand the specific occupational risks associated with certain professions to provide relevant and targeted education and preventive strategies to individuals at risk. By identifying occupations that pose a higher risk for conditions like carpal tunnel syndrome, nurses can tailor their community presentations to promote awareness and provide practical advice for prevention and early intervention.