ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
- A. Administer glucosamine supplements
- B. Turn the client every 2 hours
- C. Provide active range of motion (ROM)
- D. Provide passive range of motion (ROM)
Correct answer: D
Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.
2. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?
- A. The UAP puts shoes on the client
- B. The UAP removes floor rugs and loose objects from the path
- C. The UAP walks to the side and slightly in front of the client
- D. The UAP uses a transfer (gait) belt
Correct answer: C
Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.
3. The following client come to the ophthalmology clinic. Which client needs to be seen first?
- A. Client who had recent cataract surgery and has worsening vision
- B. Client with an absent red reflex on ophthalmic examination
- C. Client with an intraocular pressure of 24 mm Hg
- D. Client with a tearing, reddened eye with exudate
Correct answer: A
Rationale: Worsening vision after cataract surgery requires immediate attention to prevent complications.
4. A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?
- A. Avoid exercise during flare-ups
- B. Do high impact exercises like running
- C. Establish a regular sleep pattern
- D. Increase calcium and caffeine intake
Correct answer: C
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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