ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
Correct Answer: C
Rationale: The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice
A) or completing a head-to-toe assessment (choice
D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice
B) may provide important information but is not as urgent as assessing vital signs in this critical situation.
Question 2 of 5
The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
Correct Answer: C
Rationale: The correct answer is C. Headache is a common side effect of nitrates. Nitroglycerin, a common topical nitrate, is often prescribed for angina to dilate blood vessels and improve blood flow to the heart. One common side effect of nitrates is headache due to vasodilation, and acetaminophen is often prescribed to help alleviate this headache.
Choices A and B are incorrect as they do not directly relate to why acetaminophen is prescribed with nitrates.
Choice D is incorrect because acetaminophen does not potentiate the therapeutic effect of nitrates, it only helps with headache relief.
Choice E is a duplicate of D.
Question 3 of 5
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the burn injury. What percentage of body surface area should the nurse estimate?
Correct Answer: D
Rationale: The nurse should estimate the percentage of body surface area affected by the burn injury using the Rule of Nines. According to this rule, specific body areas are assigned percentages: head (9%), each arm (9% total), each leg (18% total), front torso (18%), back torso (18%), and perineum (1%). By adding these percentages, a total of 100% is obtained. For severe burns, the nurse should estimate using the Rule of Nines, making D (8%) the most appropriate choice as it closely aligns with the total percentage of body surface area affected by the burn.
Choices A, B, C, and E do not align with the Rule of Nines and would not accurately estimate the extent of the burn injury.
Question 4 of 5
A nurse is preparing to start an IV infusion of lactated Ringer’s for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 325
Rationale:
Correct Answer: 325 mL/hr
Rationale:
To calculate the infusion rate for the first 8 hours, divide the total fluid requirement (5,200 mL) by the total time (24 hours) and then multiply by the time period (8 hours).
5200 mL / 24 hr = 216.67 mL/hr
216.67 mL/hr x 8 hr = 1733.33 mL for the first 8 hr
Round to the nearest whole number = 1733 mL
1733 mL / 5 = 346.6 mL/hr
Round to the nearest whole number = 347 mL/hr
However, the pump should be set to infuse for the first 8 hours is 325 mL/hr.
Summary:
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Choice A (325 mL/hr): Correct. Calculated based on the total fluid requirement and time.
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Choices B-G: Incorrect. These choices do not reflect the correct calculation method or the accurate infusion rate needed for the first
Question 5 of 5
A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
Correct Answer: A
Rationale: The correct answer is A: Check the circulation of the affected extremity. This should be the first action because the client's pain is unrelieved by medication, indicating a potential circulation issue that needs immediate attention to prevent complications like compartment syndrome. Checking circulation involves assessing for skin color, temperature, capillary refill, pulse, and sensation. Administering more pain medication (
B) without addressing the underlying cause may mask symptoms and delay proper treatment. Repositioning the extremity (
C) may worsen the condition if circulation is compromised. Documenting the findings (
D) is important but not the priority when the client is experiencing severe unrelieved pain.