ATI RN
Multi Dimensional Care | Final Exam
1. 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.
2. What may be a cause of conductive hearing loss?
- A. Prolonged exposure to loud noises
- B. Medications
- C. Presbycusis
- D. Otitis media
Correct answer: D
Rationale: Otitis media can cause conductive hearing loss by affecting the middle ear.
3. The client with systemic sclerosis (Scleroderma) is experiencing Raynaud's phenomenon. What assessment finding does the nurse anticipate?
- A. Excessive heartburn
- B. Cyanosis of the lips
- C. Excess wrinkled skin
- D. Cold and purple nailbeds
Correct answer: D
Rationale:
4. What is the priority nursing diagnosis after surgery to repair a fracture?
- A. Disturbed body image
- B. Risk for infection
- C. Risk for impaired skin integrity
- D. Acute pain
Correct answer: B
Rationale: The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.
5. What client is a susceptible host most at risk for infection?
- A. A client with leukemia
- B. A hospitalized 35-year-old-client
- C. A child who is immunized
- D. A 60-year-old client
Correct answer: A
Rationale:
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