the nurse is preparing communication for a provider the client is experiencing acute pain greater than the severity of the fracture distal to the inju

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?

A. Ischial tuberosity
B. Compartment syndrome
C. Broken arm syndrome
D. Pulmonary embolism

Correct answer: B

Rationale:

2. When providing a routine bed bath, what action does the nurse complete first?

A. Cleanse the client's feet
B. Cleanse the client's hands
C. Cleanse the client's perineal area
D. Cleanse the client's face

Correct answer: D

Rationale:

3. Which client is at highest risk of compromised immunity?

A. A client who just had surgery
B. A client who just delivered a baby
C. A client with extreme anxiety
D. A client who is awaiting surgery

Correct answer: A

Rationale:

4. 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.