Practice Question
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)
Answer Choices:
Correct Answer:
Apply a compression bandage to the client’s ankle.
Rationale:
🔹 Apply a compression bandage to the client’s ankle:
- Compression helps reduce swelling by limiting the accumulation of fluid in the interstitial tissues.
- It provides support to the injured joint and promotes stability, which is essential during the acute phase of soft tissue injury.
- Proper compression also minimizes further tissue damage and supports venous return.
🔹 Elevate the client’s foot:
- Elevation promotes venous and lymphatic drainage, reducing edema and pain.
- Raising the limb above heart level decreases hydrostatic pressure in the capillaries, which slows fluid accumulation in the injured area.
- This is particularly important during the first 24 to 48 hours post-injury.
🔹Check the client’s toes for color, temperature, and sensation:
- Neurovascular assessment is critical in injuries involving swelling or compression.
- Evaluating circulation (color and temperature), sensation, and movement (CSM) ensures that blood flow is intact and that no nerve damage or compartment syndrome is developing beneath the swelling or bandage.
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This question is from RN ATI Custom Medical Surgical Nurs Exam 2 which contains 46 questions.
More Questions from This Exam
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?
Answer Choices:
A. Uneven cast drying
B. Infection
C. Pressure from the cast
D. Poor circulation
A nurse is collecting data from a client who has rheumatoid arthritis. Which of the following is an expected finding for this client?
Answer Choices:
A. Tophi
B. Boutonniere deformity
C. Osteoma
D. Heberdens nodules
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?
Answer Choices:
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.
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?
Answer Choices:
A. Place a trochanter roll against the thigh.
B. Place a sandbag on the lateral calf.
C. Place a wedge pillow between the legs.
D. Place a footboard on the bed.
A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?
Answer Choices:
A. Internal rotation
B. Abduction
C. External rotation
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 5
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