ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client has an open wound with creamy thick yellow drainage. How would the nurse document this finding?
- A. Purulent
- B. Serosanguinous
- C. Sanguineous
- D. Serous
Correct answer: A
Rationale:
2. What are signs of hearing loss? (Select all that apply)
- A. Presence of cerumen
- B. Presence of cerumen
- C. Tinnitus
- D. Frequent asking of others to repeat statements
Correct answer: C
Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.
3. The client states, “the doctor says I am nearsighted. I do not get it.” What would be the best response by the nurse?
- A. I am sorry you did not understand. Would you like a different doctor?
- B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
- C. You will need to have glasses.
- D. This means you won’t ever need glasses.
Correct answer: B
Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.
4. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?
- A. Deliver upward abdominal thrusts with a fisted hand
- B. Perform a blind finger sweep of the child's mouth
- C. Complete five rapid back blows between the shoulder blades
- D. Encourage the child to continue coughing
Correct answer: D
Rationale:
5. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?
- A. Skin turgor
- B. Lung sounds
- C. Radial pulses
- D. Capillary refill
Correct answer: B
Rationale:
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