ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective
Correct answer: C
Rationale:
2. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?
- A. Send the client back to surgery
- B. Assess the wound for signs of dehiscence
- C. Call the provider immediately
- D. Prepare to culture the wound
Correct answer: B
Rationale:
3. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?
- A. Applying moisturizer to dry areas of the skin
- B. Massaging the client's reddened shoulders and heels
- C. Cleansing the skin routinely after soiling occurs
- D. Using a Hoyer lift for all transfers
Correct answer: B
Rationale:
4. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?
- A. Once bacterial infection has caused damage, the tissue does not regenerate.
- B. Once retinal detachment occurs, it does not return to its normal state.
- C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
- D. Glaucoma always leads to permanent blindness.
Correct answer: C
Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.
5. A client just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy?
- A. "This must be hard news to hear. Tell me more about it."?
- B. "I believe you can overcome this because I have seen how strong you are."?
- C. "Tomorrow will be better."
- D. "What is your biggest fear about this diagnosis?"?
Correct answer: A
Rationale:
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