ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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:
2. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?
- A. The client's incision site has eviscerated
- B. The client's incision site has lacerated
- C. The client's incisional site is approximated
- D. The client's incisional site has dehisced after.
Correct answer: A
Rationale:
3. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?
- A. Offer the client protein with meals to promote healing
- B. Remove the old dressing with clean gloves
- C. Teach the client about nonpharmacological pain control methods
- D. Check medication administration record (MAR)for as needed orders (PRN)
Correct answer: C
Rationale:
4. What is a classic symptom assessed in clients with lupus?
- A. Butterfly rash
- B. Chvostek's sign
- C. Ovid's sign
- D. Heberden's nodes
Correct answer: A
Rationale:
5. A nurse is caring for an immobile client. What is the priority assessment of this client?
- A. Palpate for edema
- B. Auscultate for bowel sounds
- C. Inspect the skin for injury
- D. Auscultation of lung sounds
Correct answer: C
Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.
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