ATI RN
ATI Capstone Week 10 Exam Questions
Extract:
Question 1 of 5
A client receiving infliximab through intravenous infusion is reporting difficulty swallowing. Which immediate action would the nurse take?
Correct Answer: A
Rationale: The correct immediate action for the nurse to take in this scenario is to shut off the intravenous infusion (Answer
A). Difficulty swallowing can be a sign of a severe adverse reaction such as anaphylaxis, which can be life-threatening. By stopping the infusion, the nurse can prevent further administration of the medication and assess the client's condition. This action prioritizes client safety and prevents potential complications.
Notifying the primary health care provider (Answer
B) could cause a delay in the intervention, putting the client at risk. Having the client take deep breaths and try to relax (Answer
C) is not appropriate as it does not address the potential serious complication. Obtaining a prescription for oral diphenhydramine (Answer
D) is not the immediate action needed to address the client's difficulty swallowing.
Question 2 of 5
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report:
Correct Answer: A
Rationale: The correct answer is A: Having a decreased ability to perceive colors. Cataracts are characterized by a clouding of the eye's lens, leading to reduced color perception. This occurs because the lens becomes less transparent, impacting the ability to see colors clearly.
Choices B, C, and D are incorrect as they are more indicative of other eye conditions such as glaucoma (B - loss of peripheral vision), retinal detachment (C - bright flashes of light and floaters), and macular degeneration (D - loss of central vision).
Therefore, based on the symptoms described in the question, the most likely complaint from a client with cataracts would be a decreased ability to perceive colors due to the clouding of the lens.
Question 3 of 5
A client diagnosed with bowel cancer has recently received a course of chemotherapy and has now developed stomatitis. The nurse provides instructions to the client regarding the condition and determines the need for further teaching if the client makes which statement?
Correct Answer: C
Rationale: The correct answer is C: "I need to be careful not to spread this to my family." Stomatitis is not contagious and cannot be spread to others.
Therefore, if the client expresses concern about spreading it to their family, it indicates a need for further teaching. The other options are incorrect because: A: Drinking room temperature beverages is recommended to help soothe the mouth. B: Taking analgesics can help manage the pain associated with stomatitis. D: Chemotherapy can indeed affect the immune system, leading to stomatitis as a side effect.
Question 4 of 5
A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Avoid reading and writing. Following a detached retinal repair, the client should avoid activities that strain the eyes, such as reading and writing, to prevent increased intraocular pressure and potential damage to the surgical site. Reading and writing can lead to eye strain and may impede the healing process. It is important to limit activities that require intense visual focus to promote optimal recovery. The other choices are incorrect because: A: Ambulating is generally encouraged postoperatively to prevent complications such as blood clots. B: Keeping the eye patch on during the day is crucial for protection and healing. C: Encouraging coughing and deep-breathing is important for lung expansion and preventing respiratory complications.
Question 5 of 5
Which instructions would the nurse provide to the client about the prevention and early detection of Lyme disease? (Select all that apply.)
Correct Answer: B,D,F
Rationale: The correct instructions for Lyme disease prevention are B, D, and F.
B: Avoiding heavily wooded areas reduces exposure to ticks carrying Lyme disease.
D: Wearing long-sleeved tops and pants with closed shoes minimizes skin contact with ticks.
F: Bathing after exposure and inspecting the body for ticks helps in early detection.
Avoiding insect repellent (
A) is incorrect as it is recommended for tick prevention. Dark clothing (
C) does not affect tick exposure. Immediate blood testing for a tick bite (E) is unnecessary.