ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?
- A. Stage 3
- B. Stage 4
- C. Stage 1
- D. Stage 2
Correct answer: D
Rationale:
2. 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:
3. A client with a diagnosis of Human Immunodeficiency Virus develops pneumonia. What type of infection is this?
- A. An opportunistic infection
- B. A root cause infection
- C. A pathogenic infection
- D. A nosocomial infection
Correct answer: A
Rationale: The correct answer is A: An opportunistic infection. In patients with Human Immunodeficiency Virus (HIV), infections like pneumonia are considered opportunistic because they take advantage of a weakened immune system. Option B, root cause infection, is incorrect as it does not describe the nature of the infection in relation to the patient's condition. Option C, pathogenic infection, is incorrect because while pneumonia is caused by pathogens, in the context of HIV, it is specifically termed as an opportunistic infection. Option D, nosocomial infection, is also incorrect as it refers to infections acquired in a healthcare setting, not related to the patient's HIV status.
4. What is the best goal for pain control in a client with RA?
- A. The client will eat healthy meals today and stay hydrated
- B. The client will have throughout the entire day
- C. The client will have pain less than 3/10 for most of the day
- D. The client will have pain less than 8/10 throughout the day
Correct answer: D
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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