a nurse is providing oral hygiene for an unconscious client what is the priority nursing intervention
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

Correct answer: A

Rationale:

2. What is the best nursing intervention for a client with limited mobility who cannot move independently?

Correct answer: A

Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.

3. Which client is at highest risk of compromised immunity?

Correct answer: A

Rationale:

4. A client is diagnosed with glaucoma. The provider needs to determine if it is open-angle glaucoma or closed-angle glaucoma. What test does the nurse anticipate?

Correct answer: B

Rationale: Gonioscopy is the appropriate test to anticipate in this scenario. It is used to distinguish between open-angle and closed-angle glaucoma by examining the angle where the iris meets the cornea. Choice A, ultrasonic imaging, is not typically used to differentiate between these types of glaucoma. Choice C, corneal staining, is used to detect corneal abrasions and defects, not to differentiate between types of glaucoma. Choice D, electroretinography, is a test that measures the electrical responses of various cell types in the retina and is not specific to differentiating between open-angle and closed-angle glaucoma.

5. What activities should the client avoid after cataract surgery? (Select all that apply)

Correct answer: D

Rationale: After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one’s nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.

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