ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Where will the nurse collect the most reliable source of pain assessment?
- A. From the nurse-to-nurse bedside report
- B. From a medical surgical book
- C. From the client
- D. From the client's chart
Correct answer: C
Rationale:
2. The nurse educates a client about how to reduce their risk for osteoporosis. Which of these statements by the nurse is correct? (Select all that apply)
- A. You can decrease your risk of osteoporosis by avoiding vitamin D.
- B. You can decrease your risk of osteoporosis by reducing caffeine intake.
- C. You can decrease the risk of osteoporosis by decreasing alcohol intake.
- D. You can decrease your risk of osteoporosis by reducing protein intake.
Correct answer: B
Rationale: Reducing caffeine and alcohol intake, and quitting smoking can help decrease the risk of osteoporosis.
3. 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:
4. What occurs during stage three of bone healing?
- A. Consolidation
- B. Callus formation
- C. Granulation formation
- D. Hematoma formation
Correct answer: B
Rationale: During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.
5. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?
- A. Tunnelling
- B. Eschar
- C. Blanching
- D. Cellulitis
Correct answer: B
Rationale:
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