ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?
- A. Applying moisturizer to dry areas of the skin
- B. Massaging the client's reddened shoulders and heels
- C. Cleansing the skin routinely after soiling occurs
- D. Using a Hoyer lift for all transfers
Correct answer: B
Rationale:
2. Which of the following clients should be placed in isolation for airborne precautions?
- A. A high school wrestling championship with a rash
- B. A client that recently travelled and developed a fever with cough
- C. A client with an unknown skin infection
- D. A client with heart palpitations
Correct answer: B
Rationale:
3. A client has suffered from a femur fracture. What is the nurse's priority assessment?
- A. Pain
- B. Medication history
- C. Pedal pulses
- D. Socio-economic status
Correct answer: C
Rationale:
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. 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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