ATI RN
Multi Dimensional Care | Final Exam
1. 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.
2. 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:
3. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?
- A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
- B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
- C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
- D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'
Correct answer: A
Rationale:
4. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
- A. Use a mechanical lift to reposition the client every 2 hours
- B. Elevate the client's head of the bed to 45 degrees
- C. Postpone daily bed bath
- D. Caregiver independently slides the client up in the bed
Correct answer: A
Rationale:
5. What is the best nursing intervention for a client with limited mobility who cannot move independently?
- A. Passive range of motion
- B. Pillows for positioning
- C. Active range of motion
- D. Continuous passive motion
Correct answer: A
Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.
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