ATI RN
ATI Capstone Week 9 Exam Questions
Question 1 of 5
A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?
Correct Answer: A
Rationale: The correct answer is A: Auscultate the site for a bruit. This technique is used to assess the patency of an AV graft by listening for the characteristic "swishing" sound created by blood flow through the graft. A bruit indicates good blood flow, suggesting the graft is patent.
Choice B is incorrect because blood pressure comparison between the arms is not a reliable method for assessing AV graft patency.
Choice C is incorrect because using a Doppler to auscultate the antecubital fossa does not specifically assess the patency of the AV graft.
Choice D is incorrect because checking the brachial and radial pulses simultaneously does not provide direct information about the patency of the AV graft.
Overall, auscultating the site for a bruit is the most specific and direct method for assessing the patency of an AV graft.
Question 2 of 5
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Correct Answer: D
Rationale:
Rationale: The correct answer is D. Encouraging the client to drink 2 to 3 L of water daily is essential in helping with tenacious bronchial secretions in COPD. Adequate hydration thins mucus, making it easier to expectorate. Options A, B, and C do not directly address the issue of thinning secretions. Administering oxygen helps with oxygenation, low-salt diet is for managing hypertension, and semi-Fowler's position aids with breathing but doesn't directly address secretions.
Question 3 of 5
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?
Correct Answer: D
Rationale: The correct answer is D: Oliguria. Postoperative kidney transplant patients are at risk for organ rejection, which may manifest as decreased urine output (oliguria). This is due to the body's immune system attacking the transplanted kidney. Oliguria is a critical sign that the transplanted kidney may not be functioning properly. The other choices are incorrect because:
A) Normal body temperature doesn't indicate rejection;
B) Weight loss could be due to various factors post-surgery, not necessarily organ rejection;
C) Insomnia is not a typical sign of organ rejection.
Therefore, the key manifestation to watch for in this scenario is oliguria.
Question 4 of 5
A nurse is reviewing a client's laboratory results and sees that their hemoglobin A1C is 9%. Which of the following statements from the nurse is appropriate?
Correct Answer: C
Rationale:
Rationale:
Choice C is correct because Hemoglobin A1C reflects average blood sugar levels over the past 2-3 months. A level of 9% indicates high average blood sugar.
Choice A is incorrect because A1C does not specifically indicate post-meal blood sugar.
Choice B is incorrect as A1C doesn't measure low blood sugar levels.
Choice D is incorrect as A1C reflects overall blood sugar control, not stability.
Question 5 of 5
A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?
Correct Answer: A
Rationale: The correct answer is A. A 5 lb weight gain in a short period indicates fluid overload in a client with end-stage kidney disease receiving hemodialysis. The excess fluid accumulates due to the kidneys' inability to filter it out effectively. This can lead to symptoms like edema, hypertension, and shortness of breath. Oxygen saturation and skin turgor are not specific indicators of fluid overload. Flattened neck veins are actually a sign of dehydration, not fluid overload.