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. A nurse is caring for an immobile client. What is the priority assessment in this client?
- A. Auscultation of lung sounds
- B. Assessment of skin turgor
- C. Auscultation of bowel sounds
- D. Assessment for the presence of peripheral edema
Correct answer: A
Rationale:
3. Which of the following lab tests should NOT be used for diagnosing connective tissue diseases?
- A. Rheumatoid factor (RF)
- B. Erythrocyte sedimentation rate (ESR)
- C. Anti-nuclear antibody (ANA)
- D. Thyroid stimulating hormone (TSH)
Correct answer: D
Rationale:
4. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?
- A. Applying moisturizer to dry areas of the skin
- B. Massaging the client's reddened shoulders and heels
- C. Cleansing the skin routinely after soiling occurs
- D. Using a Hoyer lift for all transfers
Correct answer: B
Rationale:
5. What is the intended outcome for the treatment of glaucoma?
- A. Improve the vision of the eye
- B. Strengthen the muscles of the eye
- C. Lower the intraocular pressure
- D. Dry up excess secretions
Correct answer: C
Rationale: The correct answer is C: Lower the intraocular pressure. The primary objective of treating glaucoma is to reduce intraocular pressure to prevent further vision loss. Choice A, 'Improve the vision of the eye,' is incorrect because while treatment may prevent vision loss, it does not necessarily improve vision. Choice B, 'Strengthen the muscles of the eye,' is incorrect as glaucoma primarily involves the optic nerve and not muscle weakness. Choice D, 'Dry up excess secretions,' is not related to the treatment goal of glaucoma which is focused on managing intraocular pressure.
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