ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, 'I don’t know what I will do if they find I have cancer.' Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: "I’m hearing that you are concerned that it might turn out that you have cancer." This response shows empathy and active listening by acknowledging the client's fear without dismissing it. It validates the client's feelings and opens up communication for further discussion and support. Option A is incorrect because it may come off as confrontational and dismissive. Option B is incorrect as it simply denies the client's worry without addressing the underlying emotion. Option D is inappropriate as it deflects the client's concern. It's essential to address the client's emotional needs in a sensitive manner during such a vulnerable time.
Question 2 of 5
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Test the drainage for glucose. This is the first action the nurse should take because clear drainage from the nose following a basal skull fracture may indicate a cerebrospinal fluid (CSF) leak. Testing the drainage for glucose can help differentiate between CSF and other types of nasal discharge. If the drainage tests positive for glucose, it confirms the presence of CSF. This finding is crucial for determining the appropriate management and potential complications associated with a CSF leak.
Summary of other choices:
A: Asking the client to blow his nose is not appropriate as it can increase intracranial pressure.
B: Suctioning the nostril can worsen the CSF leak and should be avoided.
C: Notifying the physician is important, but testing the drainage for glucose should be done first.
E, F, G: No additional options provided, but none would be more appropriate than testing the drainage for glucose.
Question 3 of 5
A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Infuse the medication with an IV pump. Theophylline requires precise dosing and continuous monitoring due to its narrow therapeutic range. Using an IV pump ensures accurate infusion rate, reducing the risk of medication errors. Administering a test dose (
A) is unnecessary for theophylline. Covering the IV container with dark paper (
C) is not relevant. Infusing the medication at 35 mg/min (
D) may exceed safe limits and cause adverse effects.
Question 4 of 5
A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?
Correct Answer: A
Rationale: The correct answer is A: pH 7.26, HCO₃ 14, PaCO₂ 30. In acute kidney injury (AKI), the kidneys cannot regulate acid-base balance, leading to metabolic acidosis. The pH is low (acidosis), HCO₃ is low indicating metabolic acidosis, and PaCO₂ is low due to compensatory respiratory alkalosis.
Choices B and D have high pH values, which are not consistent with metabolic acidosis.
Choice C has a normal HCO₃ value, which is not expected in AKI.
Choice C also has a high PaCO₂, which is not consistent with compensatory respiratory alkalosis in metabolic acidosis.
Question 5 of 5
A nurse is preparing to administer vancomycin 50 mg PO daily divided into four equal doses. The amount available is vancomycin 125 mg capsules. How many capsules should the nurse administer with each dose?
Correct Answer: 1
Rationale:
Correct Answer: A. 1 capsule
Rationale: The nurse needs to administer 50 mg daily divided into 4 equal doses. So, each dose should contain 50 mg / 4 doses = 12.5 mg. The available capsule strength is 125 mg.
Therefore, the nurse should administer 1 capsule for each dose to achieve the required dose of 12.5 mg.
Summary of Incorrect
Choices:
B. 2 capsules: This would result in a total of 250 mg per dose, exceeding the required dose of 12.5 mg.
C. 3 capsules: This would result in a total of 375 mg per dose, significantly exceeding the required dose of 12.5 mg.
D. 4 capsules: This would result in a total of 500 mg per dose, greatly exceeding the required dose of 12.5 mg.
E. 5 capsules: This would result in a total of 625 mg per dose, far exceeding the