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Ati retake mobility safety cloned assessment 1
Ati retake mobility safety cloned assessment 1
Total Questions : 14
Showing 10 questions Sign up for moreA nurse is reinforcing teaching with a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?
Explanation
A. While calcium supplementation is important for bone health, the recommended daily intake for adults at risk for osteoporosis is typically higher than 250 mg. The client may need a higher dose of calcium supplementation, along with other dietary sources of calcium.
B. While exercise is beneficial for bone health, vigorous exercise may not be suitable for all individuals, especially those at risk for osteoporosis who may have other health
concerns. Moderate-intensity exercise is generally recommended for bone health.
C. Performing moderate-intensity exercise for at least 150 minutes per week is
recommended for individuals at risk for osteoporosis. Weight-bearing and resistance exercises are particularly beneficial for improving bone density and strength.
D. Vitamin D supplementation is important for calcium absorption and bone health, but the recommended daily intake for adults at risk for osteoporosis is typically higher than 400 IU. Many healthcare providers recommend higher doses of vitamin D
supplementation, especially for individuals with low sun exposure or other risk factors for deficiency.
A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment, and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool?
Explanation
A. The list of medications is typically included in the Background component of the ISBARR communication tool, as it provides important information about the client's ongoing treatment and medications.
B. Treatment plans and interventions are generally discussed in the Assessment and Recommendation components of the ISBARR communication tool, as they involve the nurse's assessment of the client's condition and the actions recommended for continued care.
C. The Situation component of the ISBARR communication tool focuses on providing a concise summary of the client's current medical condition or status, including relevant changes since the last report or significant events that occurred during the shift.
D. Vital signs may be included as part of the Background or Assessment components of the ISBARR communication tool, depending on their relevance to the client's current condition and any changes observed during the shift.
A nurse is assisting in performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels?
Explanation
A. Maximum assist is when the client requires total assistance from one or more persons to perform the activity. In this scenario, the client is able to rise from a seated position
independently with the assistance of a cane, so maximum assist is not appropriate.
B. Minimal assist is when the client requires some assistance or supervision to perform the activity but is able to complete most of the task independently. Since the client can rise from a seated position using a cane for support, they require minimal assistance.
C. Moderate assist is when the client requires more help than minimal assist but can still contribute to the activity. Since the client can perform the task with minimal assistance, moderate assist is not appropriate.
D. No assist is when the client is able to perform the activity without any assistance.
While the client uses a cane for support, they are still able to rise from a seated position independently, so no assist is not appropriate.
The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?
Explanation
A. Changing the patient's position every 30 minutes can help prevent pressure sores but this is such a short interval. The recommended interval is at least every 2 hours.
B. Every 180 minutes (or every 3 hours) is too long of an interval between position changes for a patient at risk for skin impairment. Prolonged pressure on bony
prominences increases the risk of pressure ulcer development.
C. Every 60 minutes (or every hour) is more frequent than every 180 minutes but may
still not be sufficient for preventing pressure ulcers in an unconscious patient with limited mobility.
D. For an unconscious patient at risk for skin impairment, it is recommended to reposition the patient at least every two hours to prevent pressure ulcers and skin breakdown. This frequency is a balance between providing adequate skin protection and minimizing the risk of injury to the patient or strain to the healthcare provider.
A patient begins to fall during ambulation. The nurse would
Explanation
A. Keeping the back bent while lowering the patient is not the most appropriate postion.
B. when a patient begins to fall, it is important to control the descent to minimize injury.
The nurse should widen their stance, bring the patient's body close to provide support, bend their knees, and use the strength of their thighs to lower the patient to the ground safely.
C. Keeping the knees straight while lowering the patient increases the risk of strain or injury to the nurse's back.
D. Holding the patient upright may not be feasible if the patient is already falling, and attempting to do so may result in injury to both the patient and the nurse.
A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?
Explanation
A. Orthostatic hypotension is characterized by a drop in blood pressure upon standing,
which can lead to dizziness or lightheadedness and increase the risk of falls, especially in older adults.
B. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg
within 3 minutes of standing up.
C. Orthostatic hypotension does not directly increase the risk of a pulmonary embolism.
A pulmonary embolism is a separate medical condition involving a blockage in one of the pulmonary arteries in the lungs.
D. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure, not diastolic blood pressure.
While supervising a student who is manually transferring a patient from bed to chair, a nurse intervenes when the student transfers the patient while
Explanation
A. Standing close to the patient is a recommended practice to maintain proximity and control during patient transfers. This action is appropriate and does not require
intervention.
B. Twisting at the torso can lead to strain or injury to the nurse's back. It is essential to avoid twisting while performing patient transfers to maintain proper body mechanics and prevent injury.
C. Maintaining a wide base of support is important for stability and balance during patient transfers. This action is appropriate and promotes safe transfer techniques.
D. Using proper body mechanics is crucial for preventing injury during patient transfers.
However, the specific concern in this scenario is twisting at the torso, which can lead to strain or injury, rather than overall body mechanics.
A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?
Explanation
A. Advancing the cane 12 inches forward when walking is not a standard instruction for cane use. Typically, the cane is advanced a short distance ahead of the individual's affected leg to provide support and stability during ambulation.
B. Holding the cane on the side of the affected leg does not provide adequate support and stability to the affected side while walking.
C. When climbing stairs, the cane should be held in the hand opposite the affected leg to provide support and balance. Placing the cane at the same level as the affected leg may
lead to imbalance and difficulty ascending stairs safely.
D. This is because when using a cane for ambulation, the cane should be held on the stronger side of the body, and the user should move the cane forward simultaneously with the affected (weaker) leg. Then, the stronger leg is moved forward, which helps in maintaining balance and stability during walking.
When lying in the supine position, the patient's ankles should be flexed approximately 90 degrees so that the toes point toward the ceiling. This is referred to as
Explanation
A. The lateral position refers to lying on one side with the top hip and knee flexed and the bottom hip and knee slightly flexed.
B. Dorsiflexion is the movement of the ankle joint in which the toes are brought closer to the shin or upward, as in the supine position described.
C. Contracture refers to the shortening or tightening of muscles, resulting in the inability to move the affected joint fully.
D. Plantar flexion is the movement of the ankle joint in which the toes are pointed downward or away from the shin, opposite to the position described.
A nurse sees smoke coming from the central supply room. Which of the following actions should the nurse take first?
Explanation
A. The first priority in any emergency situation is to ensure personal safety. The nurse should immediately walk to a safe area, away from the smoke and potential danger,
before taking further action.
B. While closing doors can help contain smoke and fire, personal safety takes
precedence. The nurse should prioritize evacuating to a safe location before attempting to close doors.
C. Wrapping clients in blankets may not be appropriate in this situation, as it does not address the immediate threat posed by the smoke and potential fire. Ensuring personal safety is the priority.
D. While staying close to the ground can reduce exposure to smoke and toxic fumes in some situations, it is not the first action to take. Evacuating to a safe area is the most
important step to protect oneself from harm.
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