ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?
- A. Amount
- B. Consistency
- C. Heat
- D. Odor
Correct answer: C
Rationale:
2. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?
- A. Administer antibiotics to the client
- B. Increase the client's protein intake
- C. Teach relaxation breathing to reduce the client's pain
- D. Provide the client with anti-pyretic therapy
Correct answer: A
Rationale:
3. The client with RA complains of intensely dry eyes. What does the nurse suspect?
- A. Systemic sclerosis
- B. Sjogren's syndrome
- C. Chron's disease
- D. Discoid lupus
Correct answer: B
Rationale:
4. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
5. What phase of wound healing occurs at the time of injury and lasts about 3-5 days?
- A. Maturation
- B. Intentional
- C. Inflammatory
- D. Proliferative
Correct answer: C
Rationale:
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