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Examen

2024 ATI Custom Medical Surgical Nurse Exam 2 New Latest Versions with All Questions and 100% Correct Answers

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Question 1: A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply) A. Apply a compression bandage to the client's ankle. B. Apply heat to the client's ankle. C. Encourage the range of motion of the client's foot. D. Elevate the client's foot. E. Check the client's toes for color, temperature, and sensation. Show correct answer and explanation Explanation These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage. Applying heat to the client's ankle is not recommended as it can increase swelling and inflammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the affected area.

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Subido en
6 de junio de 2024
Número de páginas
51
Escrito en
2023/2024
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2024 ATI Custom Medical Surgical Nurse Exam
2 New Latest Versions with All Questions and
100% Correct Answers
Question 1:

A nurse in an urgent care center is caring for a client who fell and injured her
ankle. The ankle appears swollen and ecchymotic. Which of the following
interventions should the nurse take? (Select all that apply)

A. Apply a compression bandage to the client's ankle.
B. Apply heat to the client's ankle.
C. Encourage the range of motion of the client's foot.
D. Elevate the client's foot.
E. Check the client's toes for color, temperature, and sensation.
Show correct answer and explanation
Explanation

These are the correct interventions that the nurse should take. Applying a
compression bandage to the client's ankle can help reduce swelling and provide
support to the injured area. Elevating the client's foot can also help reduce
swelling by promoting venous return. Checking the client's toes for color,
temperature, and sensation is important to assess for any potential nerve or
vascular damage.

Applying heat to the client's ankle is not recommended as it can increase
swelling and inflammation. Encouraging range of motion of the client's foot is
also not recommended as it can cause further injury to the affected area.

,Question 2:

While collecting data from a client who has a cast on his right leg, a nurse
locates an area on the cast that feels warm to the touch. Which of the following
findings should the nurse identify as a complication to the client's condition?

A. Uneven cast drying
B. Infection
C. Pressure from the cast
D. Poor circulation
Show correct answer and explanation
Explanation

The nurse should identify infection as a complication to the client's condition. A
warm area on the cast could indicate the presence of an underlying infection.
The warmth could be due to an increase in blood flow to the area as the body
tries to fight off the infection.

Uneven cast drying, pressure from the cast, and poor circulation are not
complications that would cause a warm area on the cast. Uneven cast drying
could cause discomfort but would not result in warmth. Pressure from the cast
could cause skin breakdown but would not result in warmth. Poor circulation
could cause coolness or pallor but would not result in warmth.

,Question 3:

A nurse is collecting data from a client who has rheumatoid arthritis. Which of
the following is an expected finding for this client?

A. Tophi
B. Boutonniere deformity
C. Osteoma
D. Heberden's nodules
Show correct answer and explanation
Explanation

Boutonniere deformity is an expected finding for a client who has rheumatoid
arthritis. It is a type of hand deformity that can occur in people with rheumatoid
arthritis. It is characterized by a bent middle finger joint and a hyperextended
fingertip.

Tophi, osteoma, and Heberden's nodules are not expected findings for a client
who has rheumatoid arthritis. Tophi are deposits of uric acid crystals that can
occur in people with gout. Osteoma is a benign bone tumor. Heberden's nodules
are bony growths that can occur in people with osteoarthritis.




Question 4:

, 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?

A. The client is unconscious.
B. The client is unable to make vocal sounds.
C. The client can follow simple motor commands.
D. The client opens his eyes when spoken to.
Show correct answer and explanation
Explanation

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.

The client is not unconscious, as a GCS score of 3 for eye-opening indicates that
the client is able to open his eyes in response to voice. The client is not unable to
make vocal sounds, as a GCS score of 5 for best verbal response indicates that
the client is able to make vocal sounds. The client may or may not be able to
follow simple motor commands, as a GCS score of 5 for best motor response
indicates that the client is able to localize pain.
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