ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
- A. Administer glucosamine supplements
- B. Turn the client every 2 hours
- C. Provide active range of motion (ROM)
- D. Provide passive range of motion (ROM)
Correct answer: D
Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.
2. When providing a routine bed bath, what action does the nurse complete first?
- A. Cleanse the client's feet
- B. Cleanse the client's hands
- C. Cleanse the client's perineal area
- D. Cleanse the client's face
Correct answer: D
Rationale:
3. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?
- A. The client sets the cap down in a manner that does not contaminate it.
- B. The client drops the prescribed number of drops into the conjunctival sac
- C. The client washes their hands before instilling the drops
- D. The client ensures that they touch the administration dropper to the eye
Correct answer: D
Rationale: Touching the dropper to the eye contaminates it and can lead to infection.
4. A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?
- A. Delegate all client personal care to specific unlicensed assistive personnel
- B. Place the client in contact precautions
- C. Proper hand hygiene
- D. Administer pain medication
Correct answer: C
Rationale: Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.
5. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?
- A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
- B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
- C. The UAP carefully empties the indwelling catheter bag
- D. The UAP shows the client how to use the call light
Correct answer: A
Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.
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