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 is caring for 4 clients. Which of these clients will the nurse see first?
- A. A client with sudden and increasing pain in his fractured arm
- B. A client being discharged in 2 hours and needs to be taught how to use his crutches
- C. A client with RA and a scheduled pain medication
- D. A client with a fractured ankle who would like a glass of water
Correct answer: A
Rationale:
3. 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.
4. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer a protein-rich diet
- C. Offer the client a bedpan for toileting
- D. Turn the client every 4 hours
Correct answer: A
Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.
5. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?
- A. Observe client for changes in mental status
- B. Use aseptic technique for wound care and emptying of drains
- C. Keep the client's heels off the bed
- D. Perform neurovascular assessments per protocol
Correct answer: D
Rationale:
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