ATI RN
Multi Dimensional Care | Rasmusson
1. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?
- A. Tell the client’s family that they will be expected to stay overnight
- B. Apply restraints to the client
- C. Shout to the client
- D. Orient the client to the location of objects in the room
Correct answer: D
Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.
2. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?
- A. Deliver upward abdominal thrusts with a fisted hand
- B. Perform a blind finger sweep of the child's mouth
- C. Complete five rapid back blows between the shoulder blades
- D. Encourage the child to continue coughing
Correct answer: D
Rationale:
3. 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: The orthopneic position helps improve lung expansion, reducing the risk of atelectasis.
4. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?
- A. The client instills the prescribed number of eye drops into the conjunctival sac
- B. The client sets the cap to the eye drop container down in a manner that does not contaminate it
- C. The client touches the administration dropper her to the eye
- D. The client washes her hands before instilling the eye drops
Correct answer: C
Rationale:
5. A client is recovering from a fractured radius that occurred 7weeks ago. Which state of bone healing occurs at this time as the callus is restored and transformed into bone?
- A. Stage 3
- B. Stage 5
- C. Stage 1
- D. Stage 4
Correct answer: D
Rationale:
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