ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A client arrives to the emergency department by ambulance. The client has a possible traumatic brain injury after a fall from a roof. Which of the following assessment findings will the triage nurse report to the provider immediately?
Correct Answer: B
Rationale: The correct answer is B: Decreasing level of consciousness. This would be reported immediately because it indicates a worsening condition and potential deterioration in the client's neurological status. It suggests increased intracranial pressure, which is a medical emergency requiring prompt intervention to prevent further brain injury.
Choices A, C, and D do not indicate an immediate threat to the client's life or neurological status. A pupil response (choice
A) within normal limits, a temporal headache (choice
C), and a Glasgow coma score of 13 (choice
D) are concerning but do not signify an acute decline in neurological status that necessitates immediate action.
Question 2 of 5
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Correct Answer: C
Rationale: The correct answer is C: Increase in the heart rate from 88 to 110/min. This finding indicates the client may be developing hypovolemic shock because an increase in heart rate is a classic compensatory mechanism in response to decreased blood volume, which is characteristic of hypovolemic shock. The body tries to maintain cardiac output by increasing heart rate to ensure adequate tissue perfusion.
Other choices are incorrect because:
A: Increase in temperature is more indicative of an inflammatory response, not necessarily hypovolemic shock.
B: Decrease in respiratory rate is not a typical sign of hypovolemic shock.
D: Decrease in urinary output is a sign of decreased renal perfusion but not specific to hypovolemic shock.
Extract:
Nurses' Notes
0800:
Client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs continues. Yellow, watery emesis approximately 45 mL on gown; 2 to 5-second-long periods of apnea.
Vital Signs
1002:
Heart rate 86/min Respiratory rate 12/min
Oxygen saturation 86% on room air
Question 3 of 5
A nurse is caring for a client who has a seizure disorder. (Select all that apply.)
Correct Answer: A,C,E
Rationale:
Correct Answer: A, C, E
Rationale:
A: Administering supplemental oxygen helps maintain oxygen levels during a seizure, preventing hypoxia.
C: Timing the seizure duration is crucial for accurate documentation and evaluating the effectiveness of interventions.
E: Turning the client to the side helps prevent aspiration and ensures the airway remains clear.
Incorrect
Choices:
B: Restraining the client during a seizure can cause harm and increase the risk of injury.
D: Placing a tongue depressor in the client's mouth can lead to airway obstruction and injury.
In summary, administering oxygen, timing the seizure, and turning the client are essential interventions, while restraining and using tongue depressors are potentially harmful actions.
Extract:
Question 4 of 5
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Excessive thrombosis and bleeding. In DIC, there is widespread activation of the coagulation cascade leading to the formation of microthrombi in small blood vessels, causing tissue ischemia and organ dysfunction. This results in excessive clot formation (thrombosis) in some areas and simultaneous consumption of clotting factors and platelets, leading to bleeding in other areas. The other choices are incorrect because:
A) In DIC, there is consumption of clotting factors, leading to a decrease rather than an increase.
C) Platelet production may be increased initially to compensate for consumption, but it is not a progressive increase.
D) Sodium and fluid retention are not typical findings in DIC.
Question 5 of 5
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C: Defibrillation. In ventricular fibrillation, the heart is quivering and not effectively pumping blood. Defibrillation is the priority to restore normal heart rhythm by delivering an electrical shock to the heart. This is crucial to improve the chances of survival. Amiodarone (
A) and epinephrine (
B) may be used after defibrillation but are not the initial priority. Airway management (
D) is important but comes after restoring cardiac function.