ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
Correct Answer: C
Rationale: Preventing bladder distention reduces the risk of autonomic dysreflexia, which can be triggered by a full bladder or bowels. Monitoring and analgesia are not preventive measures.
Question 2 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.
Question 3 of 5
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
Correct Answer: C
Rationale: Preventing bladder distention reduces the risk of autonomic dysreflexia, which can be triggered by a full bladder or bowels. Monitoring and analgesia are not preventive measures.
Question 4 of 5
A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?
Correct Answer: C
Rationale: Preventing hip flexion avoids dislocation of the new hip joint.
Touching extremities or heels and avoiding all movement are not necessary or correct.
Question 5 of 5
A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Elevating the ankle to heart level reduces swelling per the RICE method. Tight compression, weight-bearing, and heat in the first 24 hours can worsen the injury.