ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection.
Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
Question 2 of 5
A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: Practice effective hand hygiene. This is crucial in preventing transmission of hepatitis A, which is primarily spread through fecal-oral route. Handwashing with soap and water can remove the virus from hands. Limiting physical activity (
B) and using antiseptic mouthwash (
C) are not effective in preventing transmission. Avoiding drinking water (
D) is not necessary unless the water source is contaminated.
Question 3 of 5
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
Correct Answer: B
Rationale: The correct answer is B: Phalen's test. Phalen's test is used to assess for carpal tunnel syndrome by having the client flex the wrists and press the backs of the hands together for 1 minute to compress the median nerve. This test reproduces symptoms in individuals with carpal tunnel syndrome due to increased pressure on the median nerve. Tinel's sign (
A) is used to assess for nerve compression, but it is not specific to carpal tunnel syndrome. Rinne's test (
C) is used to assess for hearing loss. Romberg test (
D) is used to assess for balance and proprioception issues.
Choices E, F, and G are not relevant to assessing carpal tunnel syndrome.
Question 4 of 5
A nurse in an ophthalmology clinic assesses a client suspected of having cataracts. What is an expected symptom?
Correct Answer: C
Rationale: The correct answer is C: Decreased ability to perceive colors. Cataracts cause clouding of the eye's lens, leading to a decrease in the perception of colors. Eye pain (
A) is not a typical symptom of cataracts. Sudden vision loss (
B) is more commonly associated with conditions like retinal detachment. Excessive tearing (
D) is not a prominent symptom of cataracts. Make sure to assess for other symptoms like blurred vision, sensitivity to light, and difficulty seeing at night.
Question 5 of 5
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C: CD4-T-cell count 180 cells/mm3. In HIV care, monitoring the CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates a weakened immune system, increasing the client's susceptibility to opportunistic infections. This value guides treatment decisions, such as initiating antiretroviral therapy. The other options, while important, do not directly reflect the client's immune status in the context of HIV. Hemoglobin and platelet counts are relevant for assessing anemia and clotting function, respectively. White blood cell count is a general indicator of infection or inflammation. Prioritizing CD4-T-cell count ensures appropriate management of HIV and prevention of complications.