a client is in the emergency room in critical condition and hypotensive her spouse is distraught what is the priority nursing action

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

A. Maintain the client's blood pressure
B. Call a chaplain
C. Provide the spouse a chair
D. Ask the client's spouse to explain what happened

Correct answer: A

Rationale:

2. The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?

A. Place the bed in the lowest possible position
B. Use the legs when lifting
C. Keep feet apart to provide a wide base of support
D. Face the direction of the movement

Correct answer: A

Rationale: Placing the bed in the lowest possible position increases the risk of injury because it does not support proper body mechanics. When lifting a client, it is important to have the bed at a comfortable height to avoid strain. Using the legs when lifting (choice B) is correct as it reduces the strain on the back. Keeping feet apart to provide a wide base of support (choice C) helps with stability and balance. Facing the direction of the movement (choice D) is essential for maintaining proper alignment and reducing the risk of injury.

3. What is accurate health promotion teaching to prevent ear infection or trauma? (Select all that apply)

A. Blow nose gently without blocking nostrils
B. Wear hearing protection when exposed to loud noise
C. Avoid using cotton-tipped applicators to clean the external ear
D. All of the above

Correct answer: D

Rationale: The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.

4. What is not a nursing intervention for a client with osteoporosis?

A. Nurse will encourage the intake of adequate amounts of calcium and vitamin D
B. Nurse will encourage the client to complete weight-bearing exercises
C. Nurse will encourage the client to avoid muscle strengthening exercises
D. Nurse will encourage the client to avoid repetitive movements

Correct answer: C

Rationale: The correct answer is C. Avoiding muscle strengthening exercises is not recommended for clients with osteoporosis; on the contrary, weight-bearing exercises are beneficial. Choice A is correct as ensuring adequate calcium and vitamin D intake is essential for bone health. Choice B is also correct as weight-bearing exercises help improve bone density. Choice D is incorrect because avoiding repetitive movements is not a standard nursing intervention for osteoporosis.