ATI RN
ATI Capstone Exam 1 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice
A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice
B) and hair loss (choice
C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
Question 2 of 5
A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Verify the provider’s prescription to discontinue the tube. This is the first step because removing an NG tube without a prescription could lead to serious complications. The nurse must ensure that it is safe and appropriate to remove the tube as per the provider's orders. Disconnecting the tube from the wall suction (
B) should only be done after verifying the prescription. Performing hand hygiene (
C) and providing mouth care to the client (
D) are important steps in the process but should come after confirming the prescription.
Question 3 of 5
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice
A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice
B) and hair loss (choice
C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
Question 4 of 5
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
Correct Answer: A
Rationale: The correct answer is A: Hemorrhage. Postoperative hemorrhage is a critical complication following a transurethral resection of the prostate due to the rich blood supply in the area. It can lead to hypovolemic shock and requires immediate intervention to prevent further complications. Monitoring for signs of bleeding such as increased heart rate, decreased blood pressure, and decreased urine output is crucial.
B: Infection is an important complication to monitor for but is not as immediately life-threatening as hemorrhage.
C: Urinary retention can occur postoperatively but is not as urgent as hemorrhage.
D: Pain management is important for the client's comfort, but it is not the priority in this situation.
In summary, monitoring for hemorrhage is crucial as it is the most life-threatening complication that requires immediate attention compared to the other options.
Question 5 of 5
A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (
D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (
A) is not necessary for this procedure. Positioning the client supine with knees bent (
B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (
C) is not recommended for bisacodyl suppositories.