a client is bedridden and appears to be frail and malnourished which nursing interventions will increase the risk of pressure injury

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.