ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?
- A. Fistula
- B. Hemorrhage
- C. Evisceration
- D. infection
Correct answer: A
Rationale:
2. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct answer: D
Rationale:
3. 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:
4. A client has a new arm cast. What is incorrect teaching by the nurse?
- A. Use a sling to alleviate fatigue
- B. Elevate the arm above the heart to reduce swelling
- C. Report ‘hot spots’ felt under the cast
- D. Sudden increase in drainage is expected
Correct answer: D
Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
5. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?
- A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
- B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
- C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
- D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'
Correct answer: A
Rationale:
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