ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
Correct Answer: B
Rationale: The correct answer is B: Maintain the airway. During the resuscitation phase of burn injuries, priority is given to ensuring airway patency to prevent respiratory distress and failure. Burns to the face, chest, and abdomen can lead to airway compromise due to swelling and damage. Maintaining the airway is crucial to ensure adequate oxygenation and ventilation. Pain management (choice
A) is important but not the priority in this phase. Inserting a urinary catheter (choice
C) is not a priority during the resuscitation phase. Initiating fluid resuscitation (choice
D) is important but only after ensuring airway patency.
Question 2 of 5
A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
Correct Answer: C
Rationale: The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice
A) or completing a head-to-toe assessment (choice
D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice
B) may provide important information but is not as urgent as assessing vital signs in this critical situation.
Question 3 of 5
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)
Correct Answer: B,C
Rationale: The correct answers are B: Hypotension and C: Poor skin turgor. In a client with frequent vomiting and diarrhea, fluid loss leads to dehydration, causing hypotension and poor skin turgor. Hypotension results from decreased circulating blood volume due to fluid loss. Poor skin turgor occurs due to decreased skin elasticity from dehydration.
Choices A, D, and E are incorrect. Fat neck veins are not typical findings in dehydration. Bradycardia is not expected in dehydration; tachycardia is more common due to compensatory mechanisms to maintain cardiac output. Pale yellow urine is indicative of concentrated urine, not a typical finding in dehydration.
Question 4 of 5
A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?
Correct Answer: A
Rationale: The correct answer is A: "I will lie on my left side to sleep at night." This position helps prevent acid from flowing back into the esophagus due to the anatomical positioning of the stomach and esophagus. When lying on the left side, the stomach is positioned below the esophagus, reducing the likelihood of reflux.
Incorrect choices:
B: Lying on the right side can worsen reflux symptoms as it allows stomach acid to flow back into the esophagus more easily.
C: Sleeping on the back with the head flat may not be as effective in preventing reflux compared to the left side position.
D: Sleeping on the stomach with the head flat can exacerbate reflux symptoms by putting pressure on the stomach and pushing acid back up into the esophagus.
Question 5 of 5
A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?
Correct Answer: B
Rationale: The correct answer is B: Chew on sugarless gum or suck on hard candies. Diphenhydramine commonly causes dry mouth as a side effect due to its anticholinergic properties. Chewing on sugarless gum or sucking on hard candies stimulates saliva production, helping to alleviate dry mouth. Administering the medication with food (choice
A) is not directly related to treating dry mouth. Placing a humidifier at the bedside (choice
C) may help with dry throat but not specifically dry mouth caused by diphenhydramine. Discontinuing the medication (choice
D) without consulting the provider is not recommended as it may lead to worsening symptoms or potential withdrawal effects.