ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)
Correct Answer: A,B,C
Rationale: The correct actions to assess the posterior tibial pulse are A, B, and C. A: Palpating the area behind the ankle bone locates the posterior tibial pulse accurately. B: Using the pads of the fingers helps to detect the pulse's strength and regularity. C: Comparing pulse strength with the other leg enables the nurse to identify any discrepancies. D: Assessing for swelling or tenderness is not directly related to locating the pulse.
Therefore, choices D, E, F, and G are incorrect for assessing the posterior tibial pulse.
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 providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
Correct Answer: A
Rationale: The correct answer is A. Eating a high fiber diet does not directly reduce the risk of developing skin cancer. The other choices are more directly related to preventing skin cancer, such as checking skin for changes (
B), avoiding tanning booths (
C), and using sunscreen on both sunny and cloudy days (D and E).
Therefore, further teaching is needed to clarify the misconception about the role of a high fiber diet in preventing skin cancer.
Question 4 of 5
A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
Correct Answer: A,B,D,E,F
Rationale: The correct findings that can cause delayed wound healing are A, B, D, E, and F.
A: Prealbumin level reflects protein status, crucial for wound healing.
B: Diabetes mellitus impairs wound healing due to poor circulation and high blood sugar.
D: Wound infection delays healing by increasing inflammation and preventing tissue repair.
E: Decreased pedal perfusion reduces blood flow to the wound site, hindering healing.
F: Fasting blood glucose levels affect the body's ability to heal due to impaired immune function and reduced collagen formation.
Incorrect choices: C - Hyperlipidemia does not directly impact wound healing; G - Insufficient information provided.
Question 5 of 5
The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?
Correct Answer: C
Rationale: The correct answer is C: A white appearance to the skin that is insensitive to touch. Frostbite initially presents with a white or pale appearance due to vasoconstriction, followed by numbness or insensitivity to touch. This occurs as a result of decreased blood flow to the affected area. As frostbite progresses, the skin may turn blue or purplish due to tissue damage. Red skin with edema in the nail beds (
Choice
A) is more indicative of inflammation or infection rather than frostbite. Black fingertips surrounded by an erythematous rash (
Choice
B) may suggest gangrene, a severe complication of untreated frostbite. A pink edematous hand (
Choice
D) is not characteristic of frostbite, as it typically presents with a white or bluish discoloration.