ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?
- A. "Ice packs can be used to reduce swelling but should be removed after 20 minutes."?
- B. "Heat always makes the swelling go down. You do not need any other interventions."?
- C. "Try high impact exercise exercise like running to loosen up your joints and reduce pain."?
- D. "Apply ice packs. It is generally okay to keep them on for up to one hour at a time."?
Correct answer: A
Rationale:
2. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?
- A. Shearing or friction
- B. Twisting and bending
- C. Pressure or gravity
- D. Chemical or pressure
Correct answer: A
Rationale:
3. What is one of the earliest signs of fat embolism syndrome?
- A. Paresthesia
- B. Severe pain in the affected limb unrelieved by medication
- C. Edema
- D. Hypoxemia
Correct answer: D
Rationale: Hypoxemia is one of the earliest signs of fat embolism syndrome. In fat embolism syndrome, fat globules enter the bloodstream and can obstruct blood flow in the lungs, leading to hypoxemia. Paresthesia, severe pain unrelieved by medication, and edema are not typically among the earliest signs of fat embolism syndrome.
4. What is the nurse's priority action for a client with compromised immunity?
- A. Wash hands before entering the client's room
- B. Take the client's vital signs every 4 hours
- C. Determine whether it is temporary or permanent
- D. Teach the family members to receive the flu shot annually
Correct answer: A
Rationale:
5. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?
- A. 15 degrees
- B. 0 degrees
- C. 90 degrees
- D. 30 degrees
Correct answer: C
Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.
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