ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is caring for an immobile client. What is the priority assessment in this client?
- A. Auscultation of lung sounds
- B. Assessment of skin turgor
- C. Auscultation of bowel sounds
- D. Assessment for the presence of peripheral edema
Correct answer: A
Rationale:
2. What may be a cause of conductive hearing loss?
- A. Prolonged exposure to loud noises
- B. Medications
- C. Presbycusis
- D. Otitis media
Correct answer: D
Rationale: Otitis media can cause conductive hearing loss by affecting the middle ear.
3. What level of Maslow's Hierarchy of needs does shelter belong to?
- A. Love and belonging
- B. Physiological
- C. Safety and security
- D. Esteem
Correct answer: C
Rationale:
4. A client arrives speaking only Spanish. What is the priority nursing intervention?
- A. Give the client a tour of the unit
- B. Verify the reason for admission
- C. Request a medical interpreter
- D. Call the chaplain for support
Correct answer: C
Rationale:
5. What device would be best to use for a client who is immobile?
- A. Standing assist device
- B. A mechanical lift
- C. Transfer board
- D. Gait belt
Correct answer: B
Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.
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