ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?
- A. Mental state
- B. Friction and shear
- C. Nutrition
- D. Sensory perception
Correct answer: A
Rationale:
2. Which organization publishes the National Patient Safety Goals?
- A. The Joint Commission
- B. Medicare
- C. The American Nurses Association
- D. The Institute of Medicine
Correct answer: A
Rationale:
3. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?
- A. The client is in a private room.
- B. The client has a vase of fresh flowers on the table
- C. The client has a dedicated vital signs machine
- D. There is hand sanitizer by the door
Correct answer: B
Rationale:
4. What is the term for a ringing in the ears reported by the client?
- A. Weber
- B. Rinne
- C. Pinna
- D. Tinnitus
Correct answer: D
Rationale: Tinnitus is the correct answer. Tinnitus refers to the perception of noise or ringing in the ears. This condition can be constant or intermittent and may be caused by various factors such as exposure to loud noises, ear infections, or underlying health conditions. Choices A, B, and C are incorrect as Weber and Rinne tests are related to hearing assessment, while the pinna is the external part of the ear responsible for collecting sound waves.
5. A client has an open wound with creamy thick yellow drainage. How would the nurse document this finding?
- A. Purulent
- B. Serosanguinous
- C. Sanguineous
- D. Serous
Correct answer: A
Rationale:
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