ATI Capstone Exam | Nurselytic

Correct Answer: D

Rationale: The correct answer is D because the weights in skeletal traction should not rest against the foot of the bed to ensure proper traction force. The weights need to hang freely to provide continuous traction on the affected body part. Placing the weights against the foot of the bed could lead to uneven or inadequate traction force, affecting the treatment effectiveness and potentially causing harm to the client.


Choice A is incorrect because the ropes should be in the center of the wheel grooves to maintain proper alignment and prevent slipping.
Choice B is incorrect because the ropes should be securely attached to the pins to ensure stability and prevent accidental detachment.
Choice C is incorrect because the weights do not need to be equal on each side; the amount of weight applied is determined by the healthcare provider based on the specific treatment plan.

Correct Answer: B

Rationale: The correct answer is B: Hyperkalemia. In extensive burn injuries, there is a significant release of potassium from damaged cells, leading to elevated serum potassium levels. This can result in cardiac arrhythmias and other complications. Hypervolemia (
A) is less likely due to fluid shifts, low hemoglobin (
C) is not typically seen in the acute phase of burn injuries, and metabolic alkalosis (
D) is not a common laboratory finding in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Crackles, peripheral edema, and weight gain. In infective endocarditis, there is a risk of developing heart failure due to damage to the heart valves. Monitoring for crackles indicates fluid accumulation in the lungs, a sign of left-sided heart failure. Peripheral edema is a result of right-sided heart failure, which can occur in infective endocarditis. Weight gain is a common symptom of heart failure due to fluid retention. Flank pain with radiation to the groin and hematuria (choice
A) are more indicative of kidney issues rather than heart failure. Respiratory distress, chest pain, and use of accessory muscles (choice
B) are more suggestive of acute pulmonary conditions. Confusion, decreasing level of consciousness, and aphasia (choice
D) are symptoms of neurological issues, not heart failure.

Correct Answer: A,B,C,E

Rationale: The correct actions are A, B, C, and E.
A) Providing diversionary activities can distract the client from pulling on the NG tube.
B) Assisting with toileting at frequent intervals helps address any discomfort or restlessness that may be contributing to the behavior.
C) Involving the family can provide additional support and understanding of the client's needs. E) Using an electronic bed alarm device can alert the nurse when the client is attempting to pull on the NG tube, allowing for timely intervention. These actions focus on addressing the underlying reasons for the behavior and ensuring the client's safety without resorting to restraints, which should be a last resort due to ethical and legal considerations.

Correct Answer: A

Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.


Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them.
Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep.
Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.