ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 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).
Question 2 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 3 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 4 of 5
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?
Correct Answer: C
Rationale: Checking the temperature assesses for fever, a key symptom of meningitis, which may present with headache and stiff neck. Other actions follow based on findings.
Question 5 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: A wedge pillow between the legs maintains proper alignment and prevents leg crossing or adduction, reducing the risk of hip dislocation. Trochanter rolls prevent external rotation, sandbags prevent foot drop, and footboards prevent plantar flexion contractures, none of which directly prevent dislocation.