ATI RN
ATI Capstone Exam 1 Questions
Extract:
Question 1 of 5
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Examining breasts in the shower with soapy hands facilitates detecting lumps, as soap allows smoother gliding. Using the palm is incorrect (finger pads are used), dimpling/discharge requires medical evaluation, and BSE should be done post-menstruation when breasts are less tender.
Question 2 of 5
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
Correct Answer: A
Rationale: An elevated white blood cell (WB
C) count indicates infection, as the body produces more WBCs to fight pathogens in an infected pressure ulcer. BUN and potassium assess kidney function and electrolyte balance, not specific to infection detection.
Question 3 of 5
Correct Answer:
Rationale:
Question 4 of 5
A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Decreasing the IV infusion rate is the appropriate action for flushing and tachycardia during vancomycin administration, indicative of vancomycin flushing syndrome (red man syndrome). Slowing the infusion reduces histamine release, alleviating symptoms. This is not anaphylaxis, changing the IV site is irrelevant, and cold compresses do not address the cause.
Question 5 of 5
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: Keeping provider and therapist contact information ensures quick access to support during early relapse signs, promoting timely intervention. Relapse has multiple causes beyond medication non-adherence, extra doses are unsafe without guidance, and excessive sleeping is not a typical early relapse sign.