ATI RN
ATI Capstone Exam 1 Questions
Extract:
Question 1 of 5
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (
A) enhance safety, electrical cords along the walls (
B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (
C) is a safe and convenient option for someone with decreased vision.
Question 2 of 5
A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B. The client with severe respiratory stridor and a deviated trachea should be assessed first as this indicates a compromised airway, which is a life-threatening emergency. Immediate intervention is crucial to prevent respiratory arrest. Clients with airway issues should always be the top priority in triage.
Other choices are incorrect because:
A: Small circular partial-thickness burn of the left calf is not immediately life-threatening and can be addressed after addressing more critical conditions.
C: Splinted open fracture of the left medial malleolus, while serious, does not present an immediate threat to the client's life compared to compromised airway.
D: Massive head injury and seizures are also serious, but in this scenario, the client with compromised airway takes precedence as airway issues can lead to rapid deterioration.
Question 3 of 5
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?
Correct Answer: A
Rationale: The correct initial action is to check the drainage for glucose (
Choice
A). This is crucial because clear drainage after a transsphenoidal hypophysectomy may indicate a cerebrospinal fluid leak, which can be confirmed by the presence of glucose in the drainage. If glucose is present, it suggests leakage of cerebrospinal fluid and requires immediate intervention to prevent complications such as infection and meningitis. The other options (B, C, and
D) are not the most appropriate initial actions. Notifying the provider, documenting the amount of drainage, or obtaining a culture can be important steps but should come after confirming the presence of glucose to address the immediate concern of a potential cerebrospinal fluid leak.
Question 4 of 5
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child’s appendix is perforated?
Correct Answer: A
Rationale: The correct answer is A: Sudden decrease in abdominal pain. A sudden decrease in abdominal pain can indicate a perforated appendix due to the release of pressure and inflammation. This sudden relief occurs when the appendix ruptures, causing the abdominal pain to subside temporarily. This is a critical sign that the appendix has perforated and requires immediate medical attention. The other choices are incorrect because: B: Absence of Rovsing’s sign is not specific to a perforated appendix. C: Low-grade fever is commonly seen in uncomplicated appendicitis and may not necessarily indicate perforation. D: A rigid abdomen is a sign of peritonitis, which can occur with a perforated appendix, but it is not as specific as the sudden decrease in pain.
Question 5 of 5
A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct action is to place a pillow under the client's head. This helps to protect the client's head from injury during the seizure. It is important to maintain a patent airway and prevent head injury. Inserting a padded tongue blade (choice
B) could cause injury or obstruct the airway. Applying a face mask for oxygen (choice
C) may not be necessary at this point and can be done after the seizure stops. Gently restraining the client's extremities (choice
D) can cause further injury. It is crucial to prioritize safety and comfort during a seizure.