ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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:
2. What are signs of hearing loss? (Select all that apply)
- A. Presence of cerumen
- B. Presence of cerumen
- C. Tinnitus
- D. Frequent asking of others to repeat statements
Correct answer: C
Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.
3. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?
- A. Avoid contact sports until the infection has cleared
- B. Use a bath sponge to cleanse the skin
- C. Wash hands with soap and water before and after touching the infected area
- D. Use an antibacterial soap when showering
Correct answer: B
Rationale:
4. The nurse is caring for a 65-year-old client and notes a temperature of 101°F. How does the nurse interpret this finding?
- A. Hyperthermia
- B. A cold environment
- C. Normal
- D. Hypothermia
Correct answer: A
Rationale: A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.
5. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?
- A. Skin turgor
- B. Lung sounds
- C. Radial pulses
- D. Capillary refill
Correct answer: B
Rationale:
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