ATI RN
ATI Custom MS Nurse Questions
Extract:
Client with head injury, Glasgow Coma Scale score of 3 for eye opening, 5 for best verbal response, 5 for best motor response
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: An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.
Extract:
Client 2 days postoperative following an above-the-knee amputation
Question 2 of 5
A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time?
Correct Answer: D
Rationale: Having the client lie prone several times each day is an appropriate nursing intervention for a client who is 2 days postoperative following an above-the-knee amputation. Lying prone can help prevent hip flexion contractures, which can occur after an above-the-knee amputation.
Extract:
Client with a lower-leg cast reporting skin irritation around the upper edge
Question 3 of 5
A nurse is collecting data from a client who reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: If a client reports skin irritation around the upper edge of a lower-leg cast, the nurse should petal the edges of the cast. This involves applying adhesive strips or moleskin around the edges of the cast to smooth them out and prevent them from rubbing against the skin.
Extract:
Client in skeletal traction
Question 4 of 5
A client returns to the surgical unit from the PACU in skeletal traction. The nurses should take action to correct. Which of the following problems with the traction setup?
Correct Answer: A
Rationale: If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or floor.
Extract:
Older adult client lying on the floor next to the bed
Question 5 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: The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.