Questions 48

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ATI Msn De5320 Fundamentals Exam Questions

Extract:


Question 1 of 5

The nurse is reviewing interventions written for a client. Which of the following the nurse will consider as being independent?

Correct Answer: B

Rationale: Repositioning every 2 hours is an independent nursing action within the nurse’s scope to prevent pressure ulcers, requiring no provider order. Administering medications or starting IV antibiotics are dependent interventions, needing a physician’s prescription.

Question 2 of 5

A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

Correct Answer: C

Rationale: Multiple sclerosis impairs balance and coordination, heightening fall risk. Hernias cause discomfort, hyperlipidemia affects lipids, and hyperthyroidism causes tremors, but they don’t directly affect mobility.

Question 3 of 5

The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include:

Correct Answer: A,C,E

Rationale: A fall-risk armband alerts staff, a low bed reduces injury risk, and an accessible call light enables assistance requests. Checking once per shift is insufficient, and four side rails may cause entrapment.

Question 4 of 5

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?

Correct Answer: B

Rationale: Passive range of motion maintains or improves joint flexibility by preventing contractures post-stroke. It does not significantly affect bone density, muscle mass, or strength.

Question 5 of 5

A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

Correct Answer: A

Rationale: Orthostatic hypotension causes dizziness upon standing, increasing fall risk. It’s defined by a systolic drop ≥20 mm Hg or diastolic ≥10 mm Hg, not 10 mm Hg systolic or 5 mm Hg diastolic. It’s unrelated to pulmonary emboli.

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