ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?
- A. Wearing a mask within three feet of the client
- B. Using standard precautions
- C. Applying hand sanitizer to gloves during cares
- D. Double gloving
Correct answer: B
Rationale:
2. 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.
3. 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.
4. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
- A. Assess the right radial pulse
- B. Call the provider
- C. Administer pain medication
- D. Assess the right pedal pulse
Correct answer: A
Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.
5. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?
- A. Remove the cast to decrease pressure
- B. Raise the arm above the level of the heart
- C. Apply heat to the affected hand
- D. Encourage range of motion
Correct answer: B
Rationale:
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