ATI RN
Multi Dimensional Care | Final Exam
1. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
2. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?
- A. Creamy pus
- B. Serous
- C. Serosanguineous
- D. Purulent exudate
Correct answer: C
Rationale:
3. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?
- A. Insert the wound and assess the drainage
- B. Apply topical ointment to the wound
- C. Call the provider to initiate antibiotics
- D. Culture the wound
Correct answer: D
Rationale:
4. 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.
5. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?
- A. Label the specimen tube
- B. Put on non-sterile gloves
- C. Gently remove the soiled dressings
- D. Irrigate the wound
Correct answer: B
Rationale:
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