ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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: Culture the wound
Rationale:
2. Which physiologic response is most likely to accompany activation of the parasympathetic nervous system?
- A. Increased heart rate
- B. Increased gastric motility
- C. Pupil dilation
- D. Sweating
Correct answer: B
Rationale: The correct answer is B: Increased gastric motility. The parasympathetic nervous system is known to promote rest and digest functions, which includes increasing gastric motility to aid in digestion. Choices A, C, and D are incorrect as they are more characteristic of the sympathetic nervous system. The sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate (Choice A), pupil dilation (Choice C), and sweating (Choice D) among other responses.
3. Cortisol is a hormone that ________
- A. is released by the hypothalamus and travels to the pituitary gland, causing it to respond.
- B. the pituitary gland releases to stimulate the adrenal gland.
- C. the adrenal gland produces that mobilizes the body to deal with stress.
- D. reduces the reuptake of the monoamine neurotransmitters.
Correct answer: C
Rationale: The correct answer is C. Cortisol is a hormone produced by the adrenal gland that mobilizes the body to deal with stress. It helps regulate metabolism, reduce inflammation, and assist in memory formulation. Choice A is incorrect as cortisol is not released by the hypothalamus and does not travel to the pituitary gland. Choice B is incorrect as cortisol is not released by the pituitary gland but acts on it to regulate hormone production. Choice D is incorrect as cortisol does not reduce the reuptake of monoamine neurotransmitters.
4. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?
- A. Monitor the patient's vital signs.
- B. Check the patient's weight daily.
- C. Measure the patient's intake and output.
- D. Monitor the patient's urine color.
Correct answer: B
Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.
5. A nurse is caring for a client with a newly inserted pacemaker. What is the most important nursing action post-procedure?
- A. Monitor the insertion site for signs of infection.
- B. Educate the client about activity restrictions.
- C. Monitor the client's heart rate and rhythm.
- D. Assess the client's lung sounds for signs of fluid overload.
Correct answer: A
Rationale: Post-procedure, monitoring the insertion site for signs of infection is crucial because it helps in early detection of any potential complications such as infection. While educating the client about activity restrictions, monitoring the client's heart rate and rhythm, and assessing lung sounds for signs of fluid overload are important aspects of care, the immediate priority post-procedure is to prevent infection at the insertion site, which could lead to serious complications.
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