ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 of 5
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
Correct Answer: C,D,E
Rationale: Night lights improve visibility, a reachable bedside table reduces unnecessary movement, and locked wheels ensure stability, all reducing fall risk. Sedatives and bed height do not directly prevent falls.
Question 2 of 5
A client who has a lower-leg cast reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Petaling the cast edges with adhesive strips smooths them, preventing skin irritation. Scratching, lotion, or bivalving are inappropriate for this issue.
Question 3 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 4 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 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.