ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is teaching a client who has out about dietary recommendations. The nurse should teach the client which of the following beverages can trigger an attack?
- A. Fruit juice
- B. Alcohol
- C. Milk
- D. Coffee
Correct answer: B
Rationale:
2. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?
- A. An adolescent who has a patella fracture and is in an immobilizer
- B. A young adult who has a femur fracture and is going to surgery in two hours
- C. A middle-aged adult who has fractured his radius and has a cast
- D. An older adult who has a hip fracture and is immobile
Correct answer: D
Rationale:
3. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?
- A. Skin turgor
- B. Lung sounds
- C. Radial pulses
- D. Capillary refill
Correct answer: B
Rationale:
4. A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective
Correct answer: C
Rationale:
5. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer a protein-rich diet
- C. Offer the client a bedpan for toileting
- D. Turn the client every 4 hours
Correct answer: A
Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.
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