ATI RN
ATI Custom MS Nurse Questions
Extract:
Client unconscious following a stroke
Question 1 of 5
A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Correct Answer: C
Rationale: The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.
Extract:
Client with a fracture
Question 2 of 5
A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?
Correct Answer: C
Rationale: When contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture, the highest priority nursing intervention to assist in meeting this outcome is to maintain immobilization and alignment for the client. This helps to ensure that the bones are in the correct position to heal properly.
Extract:
Client in halo traction to immobilize cervical spine
Question 3 of 5
A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Elevating the head of the bed can help improve the patient's comfort and reduce the risk of complications such as aspiration in a client with halo traction.
Extract:
Client with a new concussion following a motor-vehicle crash
Question 4 of 5
A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Correct Answer: D
Rationale: The nurse should monitor the client for lethargy as a manifestation of increased intracranial pressure. Increased intracranial pressure (ICP) is a rise in pressure around the brain that can occur due to various reasons such as brain injury, bleeding into the brain, swelling in the brain, or an increase in cerebrospinal fluid.
Extract:
Client who sustained a basal skull fracture, clear drainage from right nostril
Question 5 of 5
A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The first action the nurse should take is to test the drainage for glucose. Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help determine if it is CSF.