ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
Correct Answer: D
Rationale: The correct answer is D because sudden relief of pain in appendicitis could indicate a ruptured appendix, which is a surgical emergency requiring immediate intervention. This is because when the appendix ruptures, the pain initially decreases due to the release of pressure in the appendix, but the situation can quickly escalate to a life-threatening condition like peritonitis.
Choices A, B, and C all indicate ongoing symptoms of appendicitis that would warrant further assessment and intervention.
Question 2 of 5
The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)
Correct Answer: B,D,E
Rationale: The correct manifestations correlating with a digoxin level of 2.3 ng/dL are Nausea, Seeing halos around bright objects, and Photophobia. Nausea is a common side effect of digoxin toxicity. Seeing halos around bright objects is a sign of visual disturbances associated with digoxin toxicity. Photophobia is sensitivity to light, which can occur with digoxin toxicity. Increased appetite and energy levels are not typically associated with digoxin toxicity and are therefore incorrect choices.
Question 3 of 5
The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?
Correct Answer: D
Rationale:
Correct Answer: D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Rationale: Positioning the client on the abdomen helps prevent hip contractures by stretching the hip flexors and maintaining hip extension. This position also helps to prevent hip adduction contractures, which can occur due to prolonged positioning on the back. By alternating positions, the client's hip joint is kept in a more functional and extended position, reducing the risk of contractures.
Summary of other choices:
A: Maintaining the client in a supine position does not actively prevent hip contractures and may even contribute to hip flexion contractures.
B: Maintaining a high-Fowler's position when the client is in bed does not address hip extension and may lead to hip flexion contractures.
C: Elevating the stump on a pillow is important for stump care but does not specifically target prevention of hip contractures.
Question 4 of 5
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
Correct Answer: C
Rationale: The correct answer is C: Cardiac murmur. Endocarditis is an infection of the inner lining of the heart chambers and valves, which can lead to the development of a new murmur due to valve damage or vegetation formation. This can result in turbulent blood flow, causing the murmur. A friction rub (choice
A) is more indicative of pericarditis, intermittent claudication (choice
B) is associated with peripheral arterial disease, and dependent rubor (choice
D) is seen in chronic arterial insufficiency.
Therefore, recognizing a new cardiac murmur in a client with endocarditis is crucial as it can indicate complications such as valve dysfunction or embolic events.
Question 5 of 5
Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?
Correct Answer: C
Rationale:
Rationale: Cullen's sign is bluish discoloration around the umbilicus, indicating internal bleeding in acute pancreatitis. This occurs due to retroperitoneal hemorrhage tracking to the periumbilical area.
Choices A, B, and D are not associated with Cullen's sign. Pancreatic pseudocyst may present with epigastric pain, electrolyte imbalance with nausea and vomiting, and pleural effusion with dyspnea.