ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 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: The correct answer is C: Ocular trauma. Unequal pupil size, known as anisocoria, can be caused by trauma to the eye or head, leading to damage to the nerves controlling pupil size. This results in one pupil becoming fixed and dilated while the other constricts normally. Normal variation in pupil size (choice
A) is unlikely to cause such a drastic difference. Age-related changes (choice
B) typically result in bilateral changes rather than unilateral. Excessive light exposure (choice
D) can cause temporary pupil constriction but not fixed dilation and constriction pattern seen in the scenario.
Question 2 of 5
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
Correct Answer: A
Rationale: The correct answer is A: Atrial fibrillation. Atrial fibrillation is characterized by an irregular and rapid heartbeat, which aligns with the client's symptoms of irregular palpitations and rapid heart rate with a significant pulse deficit. Atrial fibrillation can result in decreased cardiac output leading to fatigue and dizziness. Sinus bradycardia (
B) and sinus tachycardia (
C) do not match the description of a rapid and irregular heart rate with a pulse deficit. First-degree AV block (
D) is characterized by a delay in conduction between the atria and ventricles, which would not cause the rapid heart rate and pulse deficit observed in this case.
Question 3 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.
Question 4 of 5
A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale:
Correct Answer: 0.5 tablets
Rationale:
1. Convert 125 mcg to mg: 125 mcg = 0.125 mg
2. Determine how many tablets needed: 0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets
3. Administer 0.5 tablets per dose.
Summary:
A. Incorrect as it does not calculate the appropriate dosage.
B. Incorrect as it does not address the dosage calculation.
C. Incorrect as it does not provide the correct calculation.
D. Incorrect as it does not offer the correct dosage.
E. Incorrect as it lacks the calculation for the dosage.
F. Incorrect as it does not address the specific question.
G. Incorrect as it does not provide the correct dosage calculation.
Question 5 of 5
A nurse is preparing to administer meperidine 35 mg IM to a client every 6 hr PRN for pain. Available is meperidine injection 75 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale:
To calculate the mL of meperidine needed per dose, we divide the desired dose (35 mg) by the concentration of the medication (75 mg/mL).
35 mg ÷ 75 mg/mL = 0.4667 mL.
Rounded to the nearest tenth, the nurse should administer 0.5 mL per dose.
Choice A (0.3 mL) is incorrect as it is too low.
Choice B (0.7 mL) is incorrect as it is too high.
Choice C (1.0 mL) is incorrect as it is significantly higher than the calculated dose.
Choice D (0.4 mL) is incorrect as it is slightly lower than the calculated dose.
Choice E, F, and G are irrelevant as the correct answer is 0.5 mL.