ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?
- A. Tunnelling
- B. Eschar
- C. Blanching
- D. Cellulitis
Correct answer: B
Rationale:
2. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)
- A. A client on birth control pills
- B. A client who is immobile
- C. A client on an anticoagulant
- D. A client with dementia who has been wandering
Correct answer: a
Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.
3. What can the nurse NOT teach a client with acquired immunodeficiency syndrome (AIDS) to reduce the risk of infection?
- A. Share toothpaste with family members
- B. Avoid raw fruits and vegetables
- C. Avoid cleaning your toothbrush with bleach
- D. Wash your hands thoroughly
Correct answer: A
Rationale:
4. The client states, “the doctor says I am nearsighted. I do not get it.†What would be the best response by the nurse?
- A. I am sorry you did not understand. Would you like a different doctor?
- B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
- C. You will need to have glasses.
- D. This means you won’t ever need glasses.
Correct answer: B
Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.
5. Which assessment is NOT a nonverbal sing of pain?
- A. Decreased attention span
- B. Grimacing
- C. Increase in heart rate
- D. Reported pain of 5/10
Correct answer: D
Rationale:
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