ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
What should the nurse do first if they are stuck by a needle?
Correct Answer: B
Rationale: In this scenario, the correct first action for a nurse who has been stuck by a needle is to flush the exposed skin with water. This is crucial because it helps to reduce the risk of infection by washing away any potential pathogens that may have been introduced through the needle stick. Immediate and thorough washing can significantly decrease the likelihood of transmission of infectious agents. Seeking medical attention (option A) is important, but it is not the first step. The priority is to prevent infection by cleaning the wound site promptly. Completing an incident report (option C) and reporting the exposure (option D) are necessary steps following the initial first aid and medical attention. However, they should not delay the immediate action of washing the exposed skin. In an educational context, this question highlights the importance of quick and appropriate response to occupational exposures in healthcare settings. Nurses need to be aware of the correct steps to take in the event of a needle stick injury to protect themselves and their patients from potential harm. Understanding the rationale behind each step is crucial in ensuring the safety and well-being of healthcare workers.
Question 2 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 3 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 4 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.
Question 5 of 5
Which of the following clients should be placed in isolation for airborne precautions?
Correct Answer: B
Rationale: In this scenario, the correct answer is option B: a client that recently traveled and developed a fever with cough. This client should be placed in isolation for airborne precautions due to the potential risk of carrying an airborne infectious disease such as tuberculosis or influenza. Option A, a high school wrestling champion with a rash, does not indicate a need for airborne precautions as rashes are typically not transmitted through the air. Option C, a client with an unknown skin infection, would not require airborne precautions unless the skin infection is associated with an airborne pathogen, which is not mentioned in the scenario. Option D, a client with heart palpitations, does not require airborne precautions as heart palpitations are not indicative of an airborne infectious disease. In an educational context, understanding the different types of precautions in healthcare settings is crucial for preventing the spread of infections. Airborne precautions are specifically used for diseases that are transmitted through the air via droplet nuclei. It is important for healthcare providers to correctly identify which clients require airborne precautions to ensure the safety of both patients and healthcare workers.