ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct answer: D
Rationale:
2. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?
- A. Insert the wound and assess the drainage
- B. Apply topical ointment to the wound
- C. Call the provider to initiate antibiotics
- D. Culture the wound
Correct answer: D
Rationale:
3. What level of Maslow's Hierarchy of needs does shelter belong to?
- A. Love and belonging
- B. Physiological
- C. Safety and security
- D. Esteem
Correct answer: C
Rationale:
4. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time and he denies any type of eye pain. Which eye disorder should the nurse suspects the clients has?
- A. Cataracts
- B. Diabetic retinopathy
- C. Corneal dystrophy
- D. Conjunctivitis
Correct answer: A
Rationale:
5. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
- A. Position the client on one side with the head turned towards you
- B. Handle dentures with care
- C. Use gentle brushing and flossing techniques for clients with fragile mucosa
- D. Have a suction apparatus ready at the bedside
Correct answer: A
Rationale:
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