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. 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 2 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 3 of 5
A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?
Correct Answer: B
Rationale: Abduction (moving the leg away from the midline) prevents hip dislocation by maintaining proper joint alignment post-arthroplasty. Internal rotation, adduction, and external rotation increase dislocation risk.
Question 4 of 5
A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Checking for injuries is the priority to assess for trauma and provide immediate care. Sedation, calling family, or applying restraints are not appropriate initial actions and may delay necessary treatment.
Question 5 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.