ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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:
2. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?
- A. PAPR mask
- B. Sterile gloves
- C. Gown
- D. Surgical mask
Correct answer: C
Rationale:
3. A nurse assesses an audible grating sound (Crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?
- A. A herniated disk in the diseased joint
- B. Pieces of bone and cartilage floating
- C. Popping bursae from standing
- D. Years of an autoimmune process
Correct answer: A
Rationale:
4. The quality and risk nurse in the local hospital is performing a hospital survey on sentinel events. Which statements would the nurse use to best describe a sentinel event?
- A. Operating room event involving the use of unsafe equipments
- B. Specific events that enable a hospital to maximize reimbursement
- C. An unexpected event involving death or serious physical or psychological injury
- D. An event that can cause serious injury to a client that should never happen in a hospital
Correct answer: C
Rationale:
5. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?
- A. Once retinal detachment occurs, it does not return to its normal state
- B. Once the tissue has necrosed from high-pressure, it does not regenerate
- C. Glaucoma always leads to permanent blindness
- D. Once bacterial infection has caused damage, the tissue does not regenerate
Correct answer: B
Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.
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