ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is caring for an immobile client. What is the priority assessment in this client?
- A. Auscultation of lung sounds
- B. Assessment of skin turgor
- C. Auscultation of bowel sounds
- D. Assessment for the presence of peripheral edema
Correct answer: A
Rationale:
2. What can the nurse NOT teach a client with acquired immunodeficiency syndrome (AIDS) to reduce the risk of infection?
- A. Share toothpaste with family members
- B. Avoid raw fruits and vegetables
- C. Avoid cleaning your toothbrush with bleach
- D. Wash your hands thoroughly
Correct answer: A
Rationale:
3. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?
- A. Deliver upward abdominal thrusts with a fisted hand
- B. Perform a blind finger sweep of the child's mouth
- C. Complete five rapid back blows between the shoulder blades
- D. Encourage the child to continue coughing
Correct answer: D
Rationale:
4. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?
- A. Non-blanching
- B. Blanching
- C. Redness
- D. Warmth
Correct answer: B
Rationale:
5. 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.
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