ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?
Correct Answer: C
Rationale: The correct answer is C: Prevents dysrhythmias. Lidocaine is a Class IB antiarrhythmic medication commonly used to prevent and treat ventricular dysrhythmias, such as ventricular fibrillation and ventricular tachycardia. It works by stabilizing the cell membranes in the heart, reducing the excitability of cardiac cells and preventing abnormal electrical activity that can lead to life-threatening arrhythmias. The other options are incorrect because lidocaine does not slow intestinal motility (
A), relieve pain (
B), or dissolve blood clots (
D). It is important for the nurse to educate the client on the purpose of the medication to ensure understanding and adherence to the treatment plan.
Question 2 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Elevate the head of the bed. This intervention helps to promote venous drainage from the head, reducing intracranial pressure. Elevating the head of the bed also helps to improve cerebral blood flow.
Choices B, C, and D are incorrect. A brightly lit environment can increase stimulation and exacerbate symptoms. Encouraging a high intake of fluids can lead to fluid overload and worsen intracranial pressure. Teaching controlled coughing and deep breathing does not directly address the increased intracranial pressure concern.
Question 3 of 5
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Correct Answer: C
Rationale: The correct answer is C: Increase in the heart rate from 88 to 110/min. This finding indicates the client may be developing hypovolemic shock because an increase in heart rate is a classic compensatory mechanism in response to decreased blood volume, which is characteristic of hypovolemic shock. The body tries to maintain cardiac output by increasing heart rate to ensure adequate tissue perfusion.
Other choices are incorrect because:
A: Increase in temperature is more indicative of an inflammatory response, not necessarily hypovolemic shock.
B: Decrease in respiratory rate is not a typical sign of hypovolemic shock.
D: Decrease in urinary output is a sign of decreased renal perfusion but not specific to hypovolemic shock.
Question 4 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 5 of 5
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
Correct Answer: C
Rationale:
Correct Answer: C. Pacemaker spikes before each QRS complex.
Rationale: In a client with a ventricular pacemaker, the pacemaker spike should precede the QRS complex since the pacemaker is responsible for initiating the electrical impulse to stimulate ventricular depolarization. This is known as ventricular pacing. The presence of the pacemaker spike before each QRS complex indicates proper functioning of the pacemaker and effective capture of the ventricles. This ensures that the heart is being paced appropriately, maintaining the heart rate and rhythm.
Summary:
A: Pacemaker spikes with each T wave - Incorrect. Pacemaker spikes should precede QRS complex, not T wave.
B: Pacemaker spikes before each P wave - Incorrect. Ventricular pacemakers are responsible for pacing the ventricles, not atria.
D: Pacemaker spikes after each QRS complex - Incorrect. Pacemaker spikes should precede QRS complex for effective pacing.