ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 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: Testing for glucose identifies a cerebrospinal fluid leak, a critical finding requiring immediate action. Other steps follow but are not the first priority.
Question 2 of 5
A nurse is caring for a client who has osteoporosis and is taking calcium carbonate. The nurse should monitor the client for which of the following adverse effects?
Correct Answer: C
Rationale: Flank pain may indicate kidney stones, a potential side effect of calcium carbonate. Urinary retention, tinnitus, and bradycardia are not commonly associated.
Question 3 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 4 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 5 of 5
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye-opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Correct Answer: D
Rationale: A GCS score of 3 for eye-opening indicates the client opens their eyes in response to voice, making option D correct. The client is not unconscious, can make vocal sounds (verbal score of 5), and may not follow commands (motor score of 5 indicates localizing pain).