ATI RN
Multi Dimensional Care | Rasmusson
1. The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?
- A. Place the bed in the lowest possible position
- B. Use the legs when lifting
- C. Keep feet apart to provide a wide base of support
- D. Face the direction of the movement
Correct answer: A
Rationale: Placing the bed in the lowest possible position increases the risk of injury because it does not support proper body mechanics. When lifting a client, it is important to have the bed at a comfortable height to avoid strain. Using the legs when lifting (choice B) is correct as it reduces the strain on the back. Keeping feet apart to provide a wide base of support (choice C) helps with stability and balance. Facing the direction of the movement (choice D) is essential for maintaining proper alignment and reducing the risk of injury.
2. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?
- A. The client instills the prescribed number of eye drops into the conjunctival sac
- B. The client sets the cap to the eye drop container down in a manner that does not contaminate it
- C. The client touches the administration dropper her to the eye
- D. The client washes her hands before instilling the eye drops
Correct answer: C
Rationale:
3. On inspection, which client does the nurse suspect of having a visual impairment?
- A. The client whose sclera is white
- B. The client who has an intact blink reflex
- C. The client who is tilting their head
- D. The client with equal pupils
Correct answer: C
Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.
4. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
- A. The nurse assesses capillary refill of 2 seconds
- B. The nurse cannot insert one finger between the cast and the skin
- C. The nurse finds 2+ pulses distal from the cast
- D. The nurse does not observe any drainage
Correct answer: B
Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.
5. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?
- A. "Ice packs can be used to reduce swelling but should be removed after 20 minutes."?
- B. "Heat always makes the swelling go down. You do not need any other interventions."?
- C. "Try high impact exercise exercise like running to loosen up your joints and reduce pain."?
- D. "Apply ice packs. It is generally okay to keep them on for up to one hour at a time."?
Correct answer: A
Rationale:
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