the nurse is caring for a client on strict bed rest which intervention is the priority when caring for this client
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

Correct answer: B

Rationale: The correct answer is to perform active range of motion exercises. When a client is on strict bed rest, performing range of motion exercises is a priority to prevent complications such as thromboembolism and muscle atrophy. Option A may be important but not the priority compared to maintaining mobility. Option C is incorrect because elevating the head of the bed to 45 degrees is not necessary for a client on strict bed rest. Option D, providing a high-fiber diet, is also not the priority intervention compared to ensuring range of motion exercises are performed.

2. A healthcare provider is caring for a client who takes an antidepressant and oral contraceptives. Which herbal supplement should the healthcare provider educate the client about due to a drug-herb interaction?

Correct answer: D

Rationale: The correct answer is D, St. John’s Wort. St. John’s Wort can interact with antidepressants and oral contraceptives, potentially reducing their efficacy. Iron supplement, garlic, and green tea are not typically known to have significant interactions with antidepressants or oral contraceptives, making them less likely to impact the client's treatment.

3. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

Correct answer: A

Rationale: The correct answer is A. Compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.

4. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

Correct answer: C

Rationale: Assessing the client’s sacrum for dependent edema is crucial in the care plan for nephritic syndrome as it is common due to protein loss. Dependent edema occurs as a result of decreased oncotic pressure from protein loss in the urine. Monitoring urine for bright-red bleeding (choice A) is more relevant to conditions like glomerulonephritis. Evaluating calorie count or protein intake (choice B) is important for other conditions but not specifically for nephritic syndrome. Monitoring for a high serum albumin level (choice D) is not typically part of the immediate care plan for nephritic syndrome.

5. The system used at the division level and forward comprises six basic modules. Which module is composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients?

Correct answer: B

Rationale: The Patient Holding Squad is the module composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients. The other choices are incorrect because a 'Treatment squad' would typically involve a broader range of medical care, an 'Area support squad' is more general and focuses on providing overall support in a specific area, and a 'Surgical squad' would be specifically focused on surgical procedures rather than general medical care for minimal care patients.

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