ATI RN
Multi Dimensional Care | Final Exam
1. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)
- A. A client on birth control pills
- B. A client who is immobile
- C. A client on an anticoagulant
- D. A client with dementia who has been wandering
Correct answer: a
Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.
2. What is an example of proper body mechanics when lifting?
- A. Lifting the object with your back
- B. Standing with a narrow stance
- C. Lifting excessive weight to strengthen the muscles
- D. Holding the object close to the body
Correct answer: D
Rationale: Proper body mechanics include holding objects close to the body to prevent injury.
3. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?
- A. Deeply palpate the area for rebound tenderness
- B. Medicate the client for pain and reassess in 60 minutes
- C. Percuss over the area for a change in tone
- D. Compare the circumference to the left calf
Correct answer: D
Rationale:
4. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
5. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?
- A. Inquire about the frequency, quality and location of the pain
- B. Get the client pain medication
- C. Ensure the client knows he will have negative effects from immobility
- D. Review the client’s medication administration record
Correct answer: A
Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.
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