ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse has documented the following wound assessment. “Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?” what stage is the wound?
- A. Stage 3
- B. Stage 4
- C. Stage 1
- D. Stage 2
Correct answer: Stage 2
Rationale:
2. Does taste perception decline with age, and are individuals taking three or more medications likely to have less taste sensitivity, requiring greater amounts of sodium and sugar to perceive these tastes?
- A. Both statements are true
- B. Both statements are false
- C. The first statement is true; the second is false
- D. The first statement is false; the second is true
Correct answer: A
Rationale: Both statements are indeed true. As people age, their taste perception tends to decline. This change can be further exacerbated by the use of multiple medications, which can potentially dull taste sensitivity even more. Consequently, these individuals often need to consume foods with higher levels of sodium and sugar in order to perceive these tastes. Choices B, C, and D are incorrect because they deny either one or both of these established facts.
3. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct answer: Increased respiratory rate from 18 to 44/min
Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.
4. What is the primary focus of Lean methodology in healthcare?
- A. Reduce healthcare costs
- B. Enhance patient satisfaction
- C. Increase patient throughput
- D. Standardize care processes
Correct answer: D
Rationale: The correct answer is D: Standardize care processes. Lean methodology in healthcare focuses on standardizing care processes to improve efficiency and reduce waste. While reducing healthcare costs and enhancing patient satisfaction are important goals in healthcare, the primary focus of Lean methodology is to standardize care processes to ensure consistent, high-quality care delivery. Increasing patient throughput may be a byproduct of implementing Lean principles but is not the primary focus.
5. The parent of a child hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. What knowledge should influence the nurse's reply?
- A. The antibiotic therapy contributes to labile blood pressure values.
- B. Hypotension leading to sudden shock can develop at any time.
- C. Acute hypertension is a concern that requires monitoring.
- D. Blood pressure fluctuations indicate that the condition has become chronic.
Correct answer: C
Rationale: Acute hypertension is a common complication of acute glomerulonephritis, requiring frequent monitoring to prevent complications such as encephalopathy or heart failure. Blood pressure fluctuations can occur but are not necessarily indicative of chronic disease.
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