ATI RN
Multi Dimensional Care | Final Exam
1. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?
- A. The client sets the cap down in a manner that does not contaminate it.
- B. The client drops the prescribed number of drops into the conjunctival sac
- C. The client washes their hands before instilling the drops
- D. The client ensures that they touch the administration dropper to the eye
Correct answer: D
Rationale: Touching the dropper to the eye contaminates it and can lead to infection.
2. What complication of fractures is caused by increased pressure which can result in decreased circulation to the area?
- A. Venous thromboembolism
- B. Acute compartment syndrome
- C. Fat embolism syndrome
- D. Hemorrhage
Correct answer: B
Rationale: Acute compartment syndrome is the correct answer. It involves increased pressure within muscles, leading to decreased blood flow and tissue damage. Venous thromboembolism (Choice A) is a condition where a blood clot forms in a vein, usually in the leg. Fat embolism syndrome (Choice C) occurs when fat globules enter the bloodstream and block blood vessels. Hemorrhage (Choice D) refers to bleeding, which can occur with fractures but does not specifically involve increased pressure leading to decreased circulation as in acute compartment syndrome.
3. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?
- A. Diagnosis
- B. Assessment
- C. Implementation
- D. Evaluation
Correct answer: B
Rationale:
4. 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:
5. What is one of the earliest signs of fat embolism syndrome?
- A. Paresthesia
- B. Severe pain in the affected limb unrelieved by medication
- C. Edema
- D. Hypoxemia
Correct answer: D
Rationale: Hypoxemia is one of the earliest signs of fat embolism syndrome. In fat embolism syndrome, fat globules enter the bloodstream and can obstruct blood flow in the lungs, leading to hypoxemia. Paresthesia, severe pain unrelieved by medication, and edema are not typically among the earliest signs of fat embolism syndrome.
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