ATI RN
ATI n269 Med Surg Comprehensive Exam Questions
Extract:
Question 1 of 5
A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to the touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing which complications?
Correct Answer: C
Rationale: Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow. The symptoms of pale, cool toes with pain and intact pulses are indicative of impaired circulation due to increased pressure, which is a hallmark of compartment syndrome. This is a medical emergency that requires prompt intervention.
Question 2 of 5
A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?
Correct Answer: A
Rationale: An S3 heart sound is known as a ventricular gallop and occurs during the rapid filling phase of the ventricle in early diastole. It is commonly heard in conditions like heart failure, where the ventricles are overfilled, or in younger individuals with healthy hearts.
Question 3 of 5
A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: Keeping the client's affected leg elevated while in bed helps reduce swelling and promotes venous return, which is important in managing DVT.
Question 4 of 5
A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was
Correct Answer: C
Rationale: Hoarseness is the earliest and most common symptom of laryngeal cancer. It occurs because the tumor affects the vocal cords, causing changes in the voice. This symptom often appears early in the disease process, especially in individuals with a history of smoking.
Question 5 of 5
A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: B,C,E
Rationale: Elevating the ankle, applying a compression bandage, and encouraging rest are appropriate actions for an acute ankle sprain to reduce swelling, support the injury, and promote healing. Passive range-of-motion exercises and applying heat can exacerbate the injury in the acute phase.