ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Test the drainage for glucose. This is the first action the nurse should take because clear drainage from the nose following a basal skull fracture may indicate a cerebrospinal fluid (CSF) leak. Testing the drainage for glucose can help differentiate between CSF and other types of nasal discharge. If the drainage tests positive for glucose, it confirms the presence of CSF. This finding is crucial for determining the appropriate management and potential complications associated with a CSF leak.
Summary of other choices:
A: Asking the client to blow his nose is not appropriate as it can increase intracranial pressure.
B: Suctioning the nostril can worsen the CSF leak and should be avoided.
C: Notifying the physician is important, but testing the drainage for glucose should be done first.
E, F, G: No additional options provided, but none would be more appropriate than testing the drainage for glucose.
Question 2 of 5
A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?
Correct Answer: D
Rationale: The correct answer is D: Heart rate 46/min. Atenolol is a beta-blocker that slows down heart rate. A heart rate of 46/min indicates bradycardia, which is a contraindication for administering atenolol. Oxygen saturation of 95% (
A) is within normal range, respiratory rate of 18/min (
B) is also normal, and blood pressure of 160/94 mm Hg (
C) may be high but not a reason to withhold atenolol. In summary, bradycardia is the key factor in withholding atenolol, as it can further decrease heart rate and lead to adverse effects.
Question 3 of 5
A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Focus on providing care that prevents life-threatening emergencies. During a disaster situation with limited staffing, the nurse's priority is to ensure the safety and well-being of the clients. By focusing on providing care that prevents life-threatening emergencies, the nurse can address immediate and critical needs to stabilize and protect clients. This action aligns with disaster protocols, which prioritize the preservation of life.
A: Reinforcing discharge teaching to clients is not a priority during a disaster situation.
B: Instructing assistive personnel to focus on clients' activities of daily living (ADLs) may not address the immediate life-threatening needs of clients during a disaster.
C: Stocking additional unit supplies is important but may not be the immediate priority when dealing with a limited staff during a disaster.
In summary, the nurse should prioritize actions that address preventing life-threatening emergencies to ensure the safety and well-being of clients during a disaster.
Question 4 of 5
A nurse is caring for a client who has a Jackson-Pratt drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
Correct Answer: C
Rationale: Rationale for Correct Answer (
C): The Jackson-Pratt drain is used to prevent fluid accumulation in the wound post-surgery, reducing the risk of infection and promoting healing. It helps to remove excess fluid and prevents seroma formation. Other
Choices:
A) Incorrect - Wound irrigations may still be necessary for wound care.
B) Incorrect - While the drain may help reduce bleeding, its primary purpose is fluid drainage.
D) Incorrect - The JP drain is not used for medication administration.
Question 5 of 5
A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Infuse the medication with an IV pump. Theophylline requires precise dosing and continuous monitoring due to its narrow therapeutic range. Using an IV pump ensures accurate infusion rate, reducing the risk of medication errors. Administering a test dose (
A) is unnecessary for theophylline. Covering the IV container with dark paper (
C) is not relevant. Infusing the medication at 35 mg/min (
D) may exceed safe limits and cause adverse effects.