ATI RN ADULT MEDICAL SURGICAL 2023 NGN/RETAKE-COMPREHENSIVE
PREDICTOR EXAM WITH CLINICAL JUDGMENT FOCUS
,
,
, Section 1: Musculoskeletal Disorders & Compartment Syndrome
1. A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg
fiberglass cast. Which of the following findings should the nurse expect?
A) Erythema of the toes
B) Capillary refill less than 2 seconds
C) Intense pain with movement ✓
D) Bounding distal pulses
Rationale: Pain that is severe, deep, and unrelenting, especially pain with passive movement of
the extremity, is the earliest and most significant indicator of compartment syndrome . Capillary
refill less than 2 seconds and bounding pulses are normal findings. Erythema may indicate
infection or skin irritation but is not an early sign of compartment syndrome.
2. A client who is 6 hours post-operative following an open reduction and internal fixation
(ORIF) of a tibial fracture reports severe pain in the affected leg that is "worse than the fracture
itself." The nurse notes the leg is swollen and tense. Which action should the nurse take first?
A) Administer prescribed PRN morphine
B) Apply ice packs to the affected leg
C) Remove the dressing and cast padding, and elevate the extremity ✓
D) Notify the healthcare provider
PREDICTOR EXAM WITH CLINICAL JUDGMENT FOCUS
,
,
, Section 1: Musculoskeletal Disorders & Compartment Syndrome
1. A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg
fiberglass cast. Which of the following findings should the nurse expect?
A) Erythema of the toes
B) Capillary refill less than 2 seconds
C) Intense pain with movement ✓
D) Bounding distal pulses
Rationale: Pain that is severe, deep, and unrelenting, especially pain with passive movement of
the extremity, is the earliest and most significant indicator of compartment syndrome . Capillary
refill less than 2 seconds and bounding pulses are normal findings. Erythema may indicate
infection or skin irritation but is not an early sign of compartment syndrome.
2. A client who is 6 hours post-operative following an open reduction and internal fixation
(ORIF) of a tibial fracture reports severe pain in the affected leg that is "worse than the fracture
itself." The nurse notes the leg is swollen and tense. Which action should the nurse take first?
A) Administer prescribed PRN morphine
B) Apply ice packs to the affected leg
C) Remove the dressing and cast padding, and elevate the extremity ✓
D) Notify the healthcare provider
