a nurse is caring for an intubated and sedated geriatric client what intervention is most appropriate for reducing the risk for a friction and shear i

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

A. Use a mechanical lift to reposition the client every 2 hours
B. Elevate the client's head of the bed to 45 degrees
C. Postpone daily bed bath
D. Caregiver independently slides the client up in the bed

Correct answer: A

Rationale:

2. What is a negative effect of immobility on the musculoskeletal system?

A. Pressure injury
B. Contractures
C. Glucose intolerance
D. Incontinence

Correct answer: B

Rationale: Contractures are a negative effect of immobility on the musculoskeletal system.

3. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

A. Stage III pressure injury
B. A stage II pressure injury
C. A non-staging pressure injury
D. Stage IV pressure injury

Correct answer: D

Rationale:

4. Which test is used in the diagnosis of osteoporosis?

A. Phalen's maneuver
B. Dual-energy X-ray absorptiometry (DXA) scan
C. Proprioception
D. Blood culture

Correct answer: B

Rationale: The correct answer is B, Dual-energy X-ray absorptiometry (DXA) scan, which is commonly used to diagnose osteoporosis by measuring bone mineral density. Phalen's maneuver (choice A) is a test used to assess for carpal tunnel syndrome and is not related to osteoporosis. Proprioception (choice C) refers to the sense of body position and is not a diagnostic test for osteoporosis. Blood culture (choice D) is used to detect infections caused by bacteria in the bloodstream and is not relevant to the diagnosis of osteoporosis.