ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?
- A. The client is in a private room.
- B. The client has a vase of fresh flowers on the table
- C. The client has a dedicated vital signs machine
- D. There is hand sanitizer by the door
Correct answer: B
Rationale:
2. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?
- A. Deliver upward abdominal thrusts with a fisted hand
- B. Perform a blind finger sweep of the child's mouth
- C. Complete five rapid back blows between the shoulder blades
- D. Encourage the child to continue coughing
Correct answer: D
Rationale:
3. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
- A. Use a mechanical lift to reposition the client every 2 hours
- B. Elevate the client's head of the bed to 45 degrees
- C. Postpone daily bed bath
- D. Caregiver independently slides the client up in the bed
Correct answer: A
Rationale:
4. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)
- A. A client on birth control pills
- B. A client who is immobile
- C. A client on an anticoagulant
- D. A client with dementia who has been wandering
Correct answer: a
Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.
5. A nurse is caring for an immobile client. What is the priority assessment of this client?
- A. Palpate for edema
- B. Auscultate for bowel sounds
- C. Inspect the skin for injury
- D. Auscultation of lung sounds
Correct answer: C
Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.
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