ATI RN
ATI Capstone Week 10 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?
Correct Answer: B
Rationale: The correct answer is B: FLACC. The FLACC scale is recommended for infants and young children who cannot verbally communicate their pain level. It assesses Face, Legs, Activity, Cry, and Consolability. This scale is particularly useful for postoperative pain assessment in infants like the 6-month-old in this scenario. The Face component looks for facial expressions indicating pain, Legs assesses the child's leg movement, Activity evaluates overall body movement, Cry measures the infant's vocalization, and Consolability checks if the infant can be comforted. The other choices are not as suitable for infants or postoperative pain assessment. Visual Analog Scale requires self-reporting, Oucher and Faces scales are more appropriate for older children who can point to a face or number to indicate pain level.
Question 2 of 5
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?
Correct Answer: B
Rationale: The correct answer is B: FLACC. The FLACC scale is recommended for infants and young children who cannot verbally communicate their pain level. It assesses Face, Legs, Activity, Cry, and Consolability. This scale is particularly useful for postoperative pain assessment in infants like the 6-month-old in this scenario. The Face component looks for facial expressions indicating pain, Legs assesses the child's leg movement, Activity evaluates overall body movement, Cry measures the infant's vocalization, and Consolability checks if the infant can be comforted. The other choices are not as suitable for infants or postoperative pain assessment. Visual Analog Scale requires self-reporting, Oucher and Faces scales are more appropriate for older children who can point to a face or number to indicate pain level.
Question 3 of 5
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse’s priority?
Correct Answer: A
Rationale: The correct answer is A: CD4-T-cell count 180 cells/mm³. This is the priority because it indicates the client's immune status and progression of HIV. A low CD4 count indicates immunosuppression, increasing the risk of opportunistic infections. Monitoring CD4 levels guides treatment decisions. The other options are not as critical. B: Positive Western blot confirms HIV diagnosis but doesn't indicate disease progression. C: Platelets and D: WBC are important but not as immediate as monitoring immune function in HIV.
Question 4 of 5
A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?
Correct Answer: C
Rationale: The correct answer is C: Notify the surgeon. When purulent drainage is observed postoperatively following a corneal transplant, it indicates a potential infection. The nurse's priority is to notify the surgeon immediately to address the infection promptly to prevent further complications. Applying a non-pressure patch (choice
A) or cleaning the eye (choice
B) may not address the underlying infection. Instilling an antibiotic solution (choice
D) without consulting the surgeon may not be appropriate as the surgeon may need to assess the situation first.
Question 5 of 5
While working in the emergency department, the unit secretary says, “We just got a call that someone with a severe peanut allergy accidentally ate peanuts and is on the way.” Which emergency equipment would the nurse gather to prepare for the client’s arrival? (Select all that apply.)
Correct Answer: A,B
Rationale: The correct answer is A,B.
A: Intubation equipment and oxygen are essential for managing anaphylaxis, as severe allergic reactions can lead to airway compromise and respiratory distress.
B: Epinephrine is the first-line treatment for anaphylaxis to reverse the allergic reaction and stabilize blood pressure.
Incorrect choices:
C: Blood administration equipment is not necessary for managing a severe peanut allergy reaction.
D: Foley catheter is unrelated to the immediate management of anaphylaxis.