ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the burn injury. What percentage of body surface area should the nurse estimate?
Correct Answer: D
Rationale: The nurse should estimate the percentage of body surface area affected by the burn injury using the Rule of Nines. According to this rule, specific body areas are assigned percentages: head (9%), each arm (9% total), each leg (18% total), front torso (18%), back torso (18%), and perineum (1%). By adding these percentages, a total of 100% is obtained. For severe burns, the nurse should estimate using the Rule of Nines, making D (8%) the most appropriate choice as it closely aligns with the total percentage of body surface area affected by the burn.
Choices A, B, C, and E do not align with the Rule of Nines and would not accurately estimate the extent of the burn injury.
Question 2 of 5
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
Correct Answer: A
Rationale: The correct answer is A: The ability to comply with anticoagulant therapy for life. This is essential because mechanical valve replacement requires lifelong anticoagulant therapy to prevent clot formation. Noncompliance can lead to serious complications such as thromboembolism or valve failure. Assessing the client's understanding, willingness, and ability to adhere to this therapy is crucial for successful outcomes.
Other options are incorrect because:
B: Body image problems are important but not essential before surgery.
C: Physical demands of lifestyle are relevant but not crucial for valve replacement.
D: Participation in cardiac rehab is beneficial post-surgery but not essential before.
Overall, the ability to comply with anticoagulant therapy is the most critical factor to assess preoperatively.
Question 3 of 5
A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?
Correct Answer: A
Rationale: The correct answer is A: The client develops a life-threatening situation. In this scenario, the nurse can remove the weights from the traction device to address the life-threatening situation promptly. Removing the weights in such a situation takes precedence over other concerns like repositioning, pain complaints, or even the need for an x-ray. Life-threatening situations must always be prioritized in patient care to ensure their safety and well-being. It is crucial for the nurse to act swiftly and appropriately in such emergencies to provide the necessary care and support to the client.
Question 4 of 5
A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
Correct Answer: D
Rationale: The correct answer is D because sudden relief of pain in appendicitis could indicate a ruptured appendix, which is a surgical emergency requiring immediate intervention. This is because when the appendix ruptures, the pain initially decreases due to the release of pressure in the appendix, but the situation can quickly escalate to a life-threatening condition like peritonitis.
Choices A, B, and C all indicate ongoing symptoms of appendicitis that would warrant further assessment and intervention.
Question 5 of 5
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for an elevated temperature. This is important because an elevated temperature could indicate infection, which is a significant concern when a client has a halo fixation device. Removing the vest daily (
Choice
A) is not recommended as it can compromise the stability of the device. Checking that the halo jacket is snug (
Choice
B) is important, but monitoring for an elevated temperature is a higher priority. Providing range of motion to the client's neck (
Choice
C) is contraindicated with a halo device as it can cause serious injury.