ATI RN
Multi Dimensional Care | Final Exam
1. On inspection, which client does the nurse suspect of having a visual impairment?
- A. The client whose sclera is white
- B. The client who has an intact blink reflex
- C. The client who is tilting their head
- D. The client with equal pupils
Correct answer: C
Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.
2. Which of the following describes a valid way to collect data for community assessment?
- A. Using a library database to conduct a literature review
- B. All of these strategies are helpful in conducting a community assessment
- C. Using surveys or questionnaires to gather information from members of the community
- D. Reading government documents to determine if similar data have already been collected
Correct answer: B
Rationale: Selecting option B is the correct choice as all the mentioned strategies in options A, C, and D are valid and useful methods for collecting data during a community assessment. Using a library database for a literature review, conducting surveys or questionnaires to gather information from community members, and reading government documents to identify existing data are essential approaches in assessing a community comprehensively.
3. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if pt:
- A. Lubricates the tip of the catheter prior to inserting into the stoma
- B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
- C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
- D. Clamps of the flow of fluid when felling uncomfortable
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
4. A nurse is assessing a school-age child with a urinary tract infection. What symptom should the nurse expect?
- A. Periorbital edema.
- B. Decreased frequency of urination.
- C. Enuresis.
- D. Diarrhea.
Correct answer: C
Rationale: The correct answer is C: Enuresis. Enuresis, which refers to involuntary urination, is a common symptom of urinary tract infections in children. Periorbital edema (choice A) is more commonly associated with conditions like nephrotic syndrome. Decreased frequency of urination (choice B) is not typically seen in urinary tract infections, as these infections often present with increased frequency. Diarrhea (choice D) is not a typical symptom of a urinary tract infection.
5. A healthcare professional is reviewing the medication administration record for a client who is receiving transdermal Fentanyl for severe pain. Which of the following medications should the healthcare professional expect to cause an adverse effect when administered concurrently with Fentanyl?
- A. Ampicillin
- B. Diazepam
- C. Furosemide
- D. Prednisone
Correct answer: B
Rationale: Diazepam, a CNS depressant, can lead to severe sedation when administered concurrently with an opioid like Fentanyl due to their additive central nervous system depressant effects. This interaction can potentiate respiratory depression and other CNS effects, increasing the risk of adverse outcomes.
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