ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: Checking capillary refill every 4 hours monitors blood flow to the extremity, ensuring adequate circulation post-surgery. Other options are not standard or necessary.
Question 3 of 5
A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?
Correct Answer: D
Rationale: Clear fluid in the ear may indicate a cerebrospinal fluid leak, a serious complication of head injury requiring immediate attention. Bruising, disorientation, and tachycardia, while concerning, are less urgent.
Question 4 of 5
A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Raising the head of the bed lowers blood pressure, reducing the risk of complications like stroke in autonomic dysreflexia. Checking for causes follows this immediate action.
Question 5 of 5
A nurse is collecting data from a client who has a short arm cast for a fractured wrist. Which of the following findings indicates impaired venous return in the affected arm?
Correct Answer: B
Rationale: A bounding distal pulse suggests impaired venous return, indicating blood is not returning properly from the arm. Wheezing, fever, and pain have other causes.