ATI RN
ATI Custom MS Nurse Questions
Extract:
Client who sustained a basal skull fracture, clear drainage from right nostril
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: 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.
Extract:
Client with an ankle sprain
Question 2 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: The nurse should instruct the client to elevate the affected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood flow to the injured area.
Extract:
Client postoperative following total hip arthroplasty
Question 3 of 5
A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?
Correct Answer: C
Rationale: An appropriate action to prevent hip dislocation in a client who is postoperative following a total hip arthroplasty is to place a wedge pillow between the legs. This helps to maintain proper alignment and prevent the legs from crossing or adducting, which can cause hip dislocation.
Extract:
Client restless following a traumatic brain injury with increased intracranial pressure
Question 4 of 5
A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?
Correct Answer: C
Rationale: An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure.
Extract:
Client difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure
Question 5 of 5
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?
Correct Answer: B
Rationale: The nurse should use the term 'postictal phase' when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.