ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Which finding is not typically associated with inflammation in a client?
- A. Pain
- B. Heat
- C. Polyuria
- D. Erythema
Correct answer: C
Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.
2. 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:
3. The following client come to the ophthalmology clinic. Which client needs to be seen first?
- A. Client who had recent cataract surgery and has worsening vision
- B. Client with an absent red reflex on ophthalmic examination
- C. Client with an intraocular pressure of 24 mm Hg
- D. Client with a tearing, reddened eye with exudate
Correct answer: A
Rationale: Worsening vision after cataract surgery requires immediate attention to prevent complications.
4. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?
- A. Administer pain medication
- B. Use proper hand hygiene and strict infection control
- C. Delegate all client personal care to specific unlicensed assistive personnel
- D. Plate the client in contact precautions
Correct answer: B
Rationale:
5. What health teaching would not help an older adult avoid a musculoskeletal injury?
- A. Avoid home modification
- B. Wear a helmet when riding a bicycle
- C. Osteoporosis screening
- D. Fall prevention
Correct answer: A
Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.
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