a nurse is providing oral hygiene for an unconscious client what is the priority nursing intervention
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

Correct answer: A

Rationale:

2. During a skin inspection at the outpatient clinic, the nurse notices patches of thick, red skin with silvery scales on the client's elbows and knees. What skin abnormality does the nurse suspect?

Correct answer: C

Rationale:

3. What is a negative effect of immobility on the cardiovascular system?

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system as it can lead to blood clots.

4. What activities should the client avoid after cataract surgery? (Select all that apply)

Correct answer: D

Rationale: After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one’s nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.

5. A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?

Correct answer: C

Rationale: Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.

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