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: Use a mechanical lift to reposition the client every 2 hours
Rationale:
2. People born during the baby boom between 1946 and 1964 tend to be alike in ways that set them apart from people born at other times due to __________ influences.
- A. age-graded
- B. history-graded
- C. nonnormative
- D. bio-historical Answer: B Page Ref: 9‒10 Skill Level: Remember Topic: The Lifespan Perspective: A Balanced Point of View Difficulty Level: Easy
Correct answer: B
Rationale: People born during the baby boom between 1946 and 1964 tend to be alike in ways that set them apart from people born at other times due to history-graded influences. These influences refer to the events and conditions that are common to a particular historical era and can significantly shape the development and experiences of individuals who live through them. The post-World War II era, economic prosperity, and social changes during the baby boom period are examples of historical events that have had a lasting impact on this generation.
3. A nurse is assessing a client who is 4 hours postpartum. Which of the following findings should the nurse report to the provider?
- A. Lochia that is red and contains small clots.
- B. Fundus firm at the umbilicus.
- C. Fundus deviated to the right.
- D. Moderate perineal pain with swelling.
Correct answer: C
Rationale: The correct answer is C. A fundus that is deviated to the right may indicate a full bladder, which should be addressed postpartum. Choice A is incorrect because red lochia with small clots is expected during the early postpartum period. Choice B is incorrect as the fundus should be firm and midline, not at the umbilicus. Choice D is incorrect as perineal pain and swelling are common postpartum findings that do not require immediate reporting to the provider.
4. A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?
- A. Clay-colored stools.
- B. Hypertension.
- C. Stridor.
- D. Elevated temperature.
Correct answer: A
Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.
5. A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?
- A. Provide chicken with cream sauce.
- B. Avoid serving fish with fins and scales.
- C. Provide unleavened bread.
- D. Avoid serving foods containing lamb.
Correct answer: C
Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include avoiding leavened bread. Providing unleavened bread aligns with these restrictions and ensures the client's observance of the holiday. Choices A, B, and D are incorrect because serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not specific dietary requirements related to observing Passover in Orthodox Judaism.
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