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. A man has been admitted to the hospital unit with a medical diagnosis of COPD. He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing?
- A. Prone position
- B. Sim's position
- C. Lateral position
- D. Fowler's position
Correct answer: D
Rationale:
3. 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.
4. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?
- A. The client refused her pain medication this morning and is doing physical therapy.
- B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
- C. The client reports intermittent flatus and minor abdominal discomfort.
- D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.
Correct answer: D
Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.
5. 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.
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