ATI RN
ATI Capstone Exam 1 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Decrease the infusion rate on the IV. Flushing of the neck and tachycardia are common signs of "Red Man Syndrome," a potential adverse reaction to vancomycin infusion. Decreasing the infusion rate can help alleviate these symptoms. Documentation (
B) of an anaphylactic reaction is inaccurate because these symptoms are not indicative of an anaphylactic reaction. Changing the IV site (
C) is unnecessary as the symptoms are likely due to the medication itself. Applying cold compresses (
D) is not effective for this reaction.
Question 2 of 5
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Severe headache. Meningitis commonly presents with severe headache due to inflammation of the meninges. This is a classic symptom and should be expected during assessment. Blurred vision (
A) is not a typical finding in meningitis. Being oriented to person, place, and year (
C) is a sign of intact mental status, which may not be present in someone with meningitis. Bradycardia (
D) is not a common finding in meningitis; tachycardia is more likely due to the body's response to infection.
Question 3 of 5
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Administer an antiemetic prior to the procedure. This is important because chemotherapy often causes nausea and vomiting. Administering an antiemetic helps prevent or reduce these side effects, promoting client comfort and compliance with treatment.
Choice A is incorrect because dark stools are not a common side effect of chemotherapy for ovarian cancer.
Choice B is incorrect as using mouthwash before therapy may not be relevant to chemotherapy administration.
Choice D is incorrect as flossing frequency is not directly related to chemotherapy treatment.
Question 4 of 5
A nurse is caring for four clients who have drainage tubes. Which of the following clients is at risk for hypokalemia?
Correct Answer: D
Rationale: The correct answer is D. The client with a nasogastric tube to suction is at risk for hypokalemia because suctioning can lead to loss of gastric contents, which contain potassium. This can result in decreased potassium levels in the body, leading to hypokalemia.
A: The client with a tracheostomy tube attached to humidified oxygen is not at risk for hypokalemia as oxygen therapy does not directly impact potassium levels.
B: The client with an indwelling urinary catheter to gravity drainage is not at risk for hypokalemia as urinary drainage does not affect potassium levels significantly.
C: The client with a chest tube to water seal is not at risk for hypokalemia as chest tube drainage does not lead to potassium loss.
In summary, choice D is correct because suctioning via a nasogastric tube can cause potassium loss, while choices A, B, and C are incorrect as they do not directly impact potassium levels.
Question 5 of 5
A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct response is D: The client must provide permission to share the records with you. This is the correct answer because under HIPAA regulations, a client's medical records are confidential and can only be shared with the client's explicit permission. The nurse cannot disclose the records to a family member without the client's consent. Option A is incorrect because the ethics committee does not handle individual requests for medical records. Option B is incorrect as the nursing supervisor cannot release medical records without proper authorization. Option C is incorrect as the healthcare provider cannot share the information without the client's consent.