ATI RN
Multi Dimensional Care | Rasmusson
1. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?
- A. Encouraging bedrest
- B. Applying antiembolism stockings
- C. Tell the client to take anticoagulants
- D. Teaching about smoking cessation
Correct answer: B
Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.
2. Which of the following nonpharmacological methods cannot be used to manage the chronic pain of a client with rheumatoid arthritis?
- A. Adequate rest
- B. Heat for 20-30 minutes
- C. Hot showers
- D. Ice for 2 hours at a time
Correct answer: D
Rationale:
3. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?
- A. Shearing or friction
- B. Twisting and bending
- C. Pressure or gravity
- D. Chemical or pressure
Correct answer: A
Rationale:
4. A client has a fractured right arm. What should the nurse do first?
- A. Apply ice to the fracture site
- B. Administer pain medications
- C. Remove the client’s bracelet and rings from the right arm
- D. Send the client to radiology for an x-ray
Correct answer: C
Rationale: The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.
5. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present
Correct answer: D
Rationale:
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