ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Correct Answer: C
Rationale:
Correct Answer: C. Remind the client to look for food on the left side of the tray.
Rationale: Due to homonymous hemianopsia (loss of half of the visual field), the client may have difficulty seeing items on the right side. By reminding the client to focus on the left side, the nurse helps compensate for the visual deficit, improving the client's ability to locate and eat food.
Summary of Incorrect
Choices:
A. Providing a nonskid mat does not address the visual deficit and plate movement is not the primary issue.
B. Encouraging wide grip utensils does not address the client's visual impairment and may not improve the ability to locate food.
D. Encouraging the client to use his right hand does not address the visual deficit and may not improve the client's ability to see food on the left side.
E, F, G: No additional choices provided.
Question 2 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.
Question 3 of 5
The emergency department nurse is preparing an infusion of IV alteplase for a client who suffered a cerebrovascular accident (CVA). Which of the following statements is accurate about the administration of alteplase?
Correct Answer: B
Rationale: The correct answer is B. Alteplase is administered as a bolus over 1-2 minutes, followed by a continuous infusion over 60 minutes. This rapid administration is crucial for the drug's thrombolytic action to dissolve the clot causing the CVA. Giving it as a bolus over 3 minutes (option
B) is not accurate, as it should be given over a shorter time frame. Option A is incorrect because alteplase can be given to patients on anticoagulant or antiplatelet therapy with caution. Option C is incorrect as the recommended time for administration is within 3 hours of symptom onset, not 90 minutes after admission. Option D is incorrect as the maximum dosage of alteplase is 0.9 mg/kg, not a fixed 120 mg dose.
Question 4 of 5
A nurse is assessing a client in the emergency department when it is noted the left pupil is enlarged and fixed while the right pupil constricts to 2mm when exposed to light. Which of the following is a possible cause of unequal pupil sizing?
Correct Answer: C
Rationale: The correct answer is C: Ocular trauma. Unequal pupil size, known as anisocoria, can be caused by trauma to the eye or head, leading to damage to the nerves controlling pupil size. This results in one pupil becoming fixed and dilated while the other constricts normally. Normal variation in pupil size (choice
A) is unlikely to cause such a drastic difference. Age-related changes (choice
B) typically result in bilateral changes rather than unilateral. Excessive light exposure (choice
D) can cause temporary pupil constriction but not fixed dilation and constriction pattern seen in the scenario.
Question 5 of 5
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
Correct Answer: A
Rationale: The correct answer is A: Atrial fibrillation. Atrial fibrillation is characterized by an irregular and rapid heartbeat, which aligns with the client's symptoms of irregular palpitations and rapid heart rate with a significant pulse deficit. Atrial fibrillation can result in decreased cardiac output leading to fatigue and dizziness. Sinus bradycardia (
B) and sinus tachycardia (
C) do not match the description of a rapid and irregular heart rate with a pulse deficit. First-degree AV block (
D) is characterized by a delay in conduction between the atria and ventricles, which would not cause the rapid heart rate and pulse deficit observed in this case.