ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?
Correct Answer: C
Rationale: In the context of systemic lupus erythematosus (SLE), the appropriate nursing intervention for a client would be to administer topical hydrocortisone (Option C). This is because SLE is an autoimmune disease that causes inflammation in various parts of the body, and corticosteroids like hydrocortisone help to reduce this inflammation and manage the symptoms of SLE. Option A, intense cold therapy to the extremities, is not appropriate for SLE as cold therapy can potentially exacerbate symptoms in individuals with autoimmune conditions by triggering inflammation and vasoconstriction. Option B, encouraging ultraviolet (UV) light exposure, is also not recommended for SLE patients as UV light can exacerbate skin symptoms and trigger flares in individuals with photosensitive lupus. Option D, administering antibiotics, is not the correct intervention for SLE as it is an autoimmune condition and not caused by a bacterial infection. Administering antibiotics would not address the underlying autoimmune response seen in SLE. Understanding these interventions in the context of SLE is crucial for nurses to provide effective care for patients with this condition. It is important for nurses to be knowledgeable about appropriate interventions to manage symptoms and improve the quality of life for individuals living with SLE.
Question 2 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 3 of 5
A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?
Correct Answer: D
Rationale: In the context of a client with impaired mobility, the correct nursing intervention to help prevent skin breakdown is option D, which is to turn the client every 2 hours. This intervention is crucial as immobility can lead to prolonged pressure on certain body areas, increasing the risk of pressure ulcers. By regularly repositioning the client, pressure is relieved, promoting circulation and reducing the likelihood of skin breakdown. Option A, assisting the client to orthopneic position, is not directly related to preventing skin breakdown. While positioning is important, it is more about optimizing respiratory function rather than addressing the issue of pressure ulcers. Option B, offering the client a bedpan for toileting, and option C, offering a protein-rich diet, are not directly linked to preventing skin breakdown in a client with impaired mobility. While maintaining good nutrition is important for overall health and healing, it does not directly address the primary concern of pressure ulcer prevention. Educationally, it is essential for nursing students to understand the significance of regular repositioning in clients with impaired mobility to prevent complications like pressure ulcers. This rationale highlights the importance of evidence-based interventions and critical thinking in providing optimal care for clients with specific health challenges.
Question 4 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 5 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.