ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?
- A. Non-blanching
- B. Blanching
- C. Redness
- D. Warmth
Correct answer: B
Rationale:
2. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
- A. Use a mechanical lift to reposition the client every 2 hours
- B. Elevate the client's head of the bed to 45 degrees
- C. Postpone daily bed bath
- D. Caregiver independently slides the client up in the bed
Correct answer: A
Rationale:
3. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?
- A. Collect a culture of the purulent fluid
- B. Cleanse the skin around the pins
- C. Administer an antibiotic
- D. Instruct the client to complete exercise of the affected extremity
Correct answer: A
Rationale:
4. 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.
5. Which organization publishes the National Patient Safety Goals?
- A. The Joint Commission
- B. Medicare
- C. The American Nurses Association
- D. The Institute of Medicine
Correct answer: A
Rationale:
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