ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 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: Increased heart rate is a compensatory response to hypovolemic shock. Widening pulse pressure, normal oximetry, and reflexes are not typical.
Question 2 of 5
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
Correct Answer: C
Rationale: Defibrillation is the priority for ventricular fibrillation to restore rhythm. Amiodarone, epinephrine, and airway management follow.
Question 3 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: Unequal pupils with one fixed and dilated suggest increased intracranial pressure, often from ocular or head trauma. Normal variation, aging, or light exposure do not cause this.
Question 4 of 5
What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: Fever, chills, nuchal rigidity, severe headache, and Brudzinski’s sign are classic meningitis symptoms due to meningeal inflammation. Bradycardia is not typical; tachycardia is more common.
Question 5 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: Alteplase is given as a bolus over 1 minute, followed by a 60-minute infusion. Anticoagulants may be managed, the time window is 3–4.5 hours from onset, and max dose is 90 mg.