ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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:
2. What is the condition called when the client's pupils are different sizes and have been this way since childhood?
- A. Exophthalmos
- B. Anisocoria
- C. Strabismus
- D. Scleral edema
Correct answer: B
Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.
3. What nursing interventions increase the risk the pressure injuries?
- A. Padding hard surfaces
- B. Have client sit in wheelchair as much as possible
- C. Place pillows between bony surfaces
- D. Keep head of bed (HOB) at or less than 3
Correct answer: B
Rationale:
4. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?
- A. Label the specimen tube
- B. Put on non-sterile gloves
- C. Gently remove the soiled dressings
- D. Irrigate the wound
Correct answer: B
Rationale:
5. What evaluation indicates successful progress on the client goal of increasing daily physical activity?
- A. The client reports decreased social interaction
- B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
- C. The client reports a fall
- D. The client reports less fatigue walking up stairs
Correct answer: D
Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.
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