ATI RN
Multi Dimensional Care | Rasmusson
1. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?
- A. Tell the client’s family that they will be expected to stay overnight
- B. Apply restraints to the client
- C. Shout to the client
- D. Orient the client to the location of objects in the room
Correct answer: D
Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.
2. What is correct health promotion education for vision? (Select all that apply)
- A. Wear sunglasses to filter ultraviolet (UV) light
- B. Avoid nonsteroidal anti-inflammatory drug (NSAID) use
- C. Wash your hands before touching your eyelids
- D. All of The Above
Correct answer: D
Rationale: Wearing sunglasses, washing hands before touching eyelids, and wearing eye protection when working with fluids are important health promotion activities for vision.
3. 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:
4. What occurs during stage three of bone healing?
- A. Consolidation
- B. Callus formation
- C. Granulation formation
- D. Hematoma formation
Correct answer: B
Rationale: During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.
5. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?
- A. Insert the wound and assess the drainage
- B. Apply topical ointment to the wound
- C. Call the provider to initiate antibiotics
- D. Culture the wound
Correct answer: D
Rationale:
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