ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse assesses a client with a brain injury. The client opens his eyes when the nurse calls his name, does not understand questions, and brings his arm up in response to a trapezius squeeze by the nurse. How would the nurse document this client's assessment using the Glasgow Coma Scale?
Correct Answer: D
Rationale: The correct answer is D: 9. The Glasgow Coma Scale (GCS) assesses eye opening, verbal response, and motor response. In this scenario, the client opens his eyes in response to a stimulus (4 points), has no verbal response (1 point), and exhibits localizing pain motor response by bringing his arm up to the trapezius squeeze (4 points). This totals 9 points on the GCS, indicating a moderate level of consciousness.
Choices A, C, and G are incorrect as they do not accurately reflect the client's assessment findings.
Choice B is incorrect as a score of 1 on the GCS indicates the lowest level of consciousness.
Question 2 of 5
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?
Correct Answer: D
Rationale: The correct answer is D: Increased heart rate. In hypovolemic shock, the body tries to compensate for decreased blood volume by increasing heart rate to maintain adequate circulation. This is a result of the body's attempt to deliver oxygen and nutrients to vital organs despite the reduced blood volume. The other choices are incorrect because: A: Widening pulse pressure is not typically seen in hypovolemic shock; B: Pulse oximetry of 96% indicates adequate oxygen saturation, not a specific indicator of hypovolemic shock; C: Increased deep tendon reflexes are not typically associated with hypovolemic shock.
Extract:
Medical History
Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.
Nurses' Notes
Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glascow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even, unlabored and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous members are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted.
Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.
Client's family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with last dose taken this am. Also states that the client took two aspirin yesterday for a headache.
Vital Signs
Temperature 38.5° C (101.3° F)
Pulse 110/min
Blood pressure 98/60 mm Hg Respiratory rate 26/min
Oxygen saturation 93% on 2 L nasal cannula
Diagnostic Results
RBC count 5.0 (Male 4.7 to 6.1)
WBC count 9,500 mm (5,000 to 10,000/mm3) Platelets 97,000/mm3 (150,000 to 400,000/mm3) Hemoglobin 15 g/dL (Male 14 to 18 g/dL)
Hematocrit 45% (Male 42% to 52% ; Female 37% to 47%)
Glucose 186 mg/dL (74 to 106 g/dL)
Question 3 of 5
A nurse is caring for a 73-year-old client in the emergency department (ED). It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.
Correct Answer: A,B,C,G,H
Rationale:
Correct Answer: A, B, C, G
Rationale:
A: Obtaining blood cultures helps identify the causative organism for targeted antibiotic therapy.
B: Administering broad-spectrum antibiotics promptly targets potential pathogens, reducing the risk of septic shock.
C: Rapidly administering normal saline helps restore perfusion and improve hemodynamics in sepsis.
G: Measuring lactate levels aids in assessing tissue perfusion and is a key indicator of sepsis severity.
Summary of Incorrect
Choices:
D: Inserting an NG tube is not a priority in managing sepsis in the first hour.
E: Type and cross-matching for packed RBCs is not an immediate intervention for sepsis management.
F: Obtaining a urine specimen is not as crucial as the other actions in the first hour of managing sepsis.
Extract:
Question 4 of 5
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Correct Answer: B
Rationale: The correct answer is B: Increased respiratory rate. This is the earliest indicator of shock because the body initially compensates by increasing respiratory rate to improve oxygenation and perfusion. Hypotension (
A) occurs later in shock as a result of decreased cardiac output. Anuria (
C) is a late sign of shock indicating renal failure. Decreased level of consciousness (
D) occurs when brain perfusion is severely compromised.
Therefore, increased respiratory rate is the first sign of the body's attempt to compensate for decreased perfusion in shock.
Question 5 of 5
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Verapamil is a calcium channel blocker that can cause vasodilation, leading to a decrease in blood pressure. Administering it by IV bolus can result in a rapid drop in blood pressure, causing hypotension. Monitoring for hypotension is crucial to prevent complications such as dizziness, syncope, or inadequate perfusion to vital organs. Muscle pain (
B), ototoxicity (
C), and hyperthermia (
D) are not commonly associated with verapamil administration. Monitoring for these adverse effects would not be relevant in this scenario.