ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 of 5
A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?
Correct Answer: D
Rationale: Placing a pillow under the head protects the client from head injury during a seizure. Inserting objects, restraining, or forcing a supine position can cause harm or worsen the seizure.
Question 2 of 5
A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Avoiding strenuous activities for a week prevents further injury and supports recovery. Heat can worsen swelling, frequent questioning may be unnecessary, and encouraging prolonged sleep could mask worsening symptoms.
Question 3 of 5
A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?
Correct Answer: C
Rationale: A wedge pillow between the legs maintains proper alignment and prevents leg crossing or adduction, reducing the risk of hip dislocation. Trochanter rolls prevent external rotation, sandbags prevent foot drop, and footboards prevent plantar flexion contractures, none of which directly prevent dislocation.
Question 4 of 5
A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)
Correct Answer: A,B,C
Rationale: Absence of pulse, altered sensation, and cool skin indicate compartment syndrome due to increased pressure impairing blood flow and nerve function. Pain relief by narcotics and normal capillary refill are not typical signs.
Question 5 of 5
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)
Correct Answer: A,D,E
Rationale: Applying a compression bandage reduces swelling and supports the injured area. Elevating the foot promotes venous return to decrease swelling. Checking toes for color, temperature, and sensation assesses for nerve or vascular damage. Heat can increase swelling and inflammation, and encouraging range of motion may worsen the injury.