ATI RN
ATI Nur211 Capstone Questions
Extract:
Medical History
Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.
Nurses' Notes
Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glascow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even, unlabored and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous members are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted.
Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.
Client's family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with last dose taken this am. Also states that the client took two aspirin yesterday for a headache.
Vital Signs
Temperature 38.5° C (101.3° F)
Pulse 110/min
Blood pressure 98/60 mm Hg Respiratory rate 26/min
Oxygen saturation 93% on 2 L nasal cannula
Diagnostic Results
RBC count 5.0 (Male 4.7 to 6.1)
WBC count 9,500 mm (5,000 to 10,000/mm3) Platelets 97,000/mm3 (150,000 to 400,000/mm3) Hemoglobin 15 g/dL (Male 14 to 18 g/dL)
Hematocrit 45% (Male 42% to 52% ; Female 37% to 47%)
Glucose 186 mg/dL (74 to 106 g/dL)
Question 1 of 5
A nurse is caring for a 73-year-old client in the emergency department (ED). It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.
Correct Answer: A,B,C,G,H
Rationale:
Correct Answer: A, B, C, G
Rationale:
A: Obtaining blood cultures helps identify the causative organism for targeted antibiotic therapy.
B: Administering broad-spectrum antibiotics promptly targets potential pathogens, reducing the risk of septic shock.
C: Rapidly administering normal saline helps restore perfusion and improve hemodynamics in sepsis.
G: Measuring lactate levels aids in assessing tissue perfusion and is a key indicator of sepsis severity.
Summary of Incorrect
Choices:
D: Inserting an NG tube is not a priority in managing sepsis in the first hour.
E: Type and cross-matching for packed RBCs is not an immediate intervention for sepsis management.
F: Obtaining a urine specimen is not as crucial as the other actions in the first hour of managing sepsis.
Extract:
Question 2 of 5
A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?
Correct Answer: D
Rationale: The correct answer is D: Decerebrate posturing. The nurse would document this finding by observing the patient's extended arms and legs, rigid posture, and clenched fists, indicating damage to the upper brainstem. Decerebrate posturing is a more severe form of abnormal posturing than decorticate posturing (choice
B), characterized by flexed arms and clenched fists. Spinal cord degeneration (choice
A) refers to progressive damage to the spinal cord, not a specific posture. Atypical hyperreflexia (choice
C) is not a recognized clinical term related to posture.
Therefore, the correct choice is D as it accurately describes the patient's posture and neurological condition.
Question 3 of 5
A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for mechanical ventilation. In a myasthenic crisis, respiratory muscles become severely weakened, leading to respiratory failure. Mechanical ventilation is crucial to support breathing and oxygenation. Administering sedatives (choice
A) can further depress respiratory function. Instructing pursed lip breathing (choice
B) may not be sufficient in severe cases. Administering a vasoconstrictor (choice
D) is not indicated in myasthenic crisis.
Question 4 of 5
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. Hypokalemia leads to low potassium levels, affecting cardiac function. This can manifest as U wave prominence on EKG due to delayed repolarization of ventricles. Inverted P wave (choice
B) is seen in conditions like atrial ischemia, not specific to hypokalemia. Elevated ST segment (choice
C) indicates myocardial injury, not typically seen in hypokalemia. Wide QRS (choice
D) is seen in conditions like bundle branch blocks, not specific to hypokalemia. The other choices are not directly related to hypokalemia and are therefore incorrect.
Question 5 of 5
What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: The correct signs and symptoms for meningitis include fever and chills due to systemic infection, nuchal rigidity from meningeal irritation, severe headache from increased intracranial pressure, and Brudzinski's sign, which indicates meningeal irritation when the neck is flexed. Bradycardia is not a typical sign of meningitis. The summary of why the other choices are incorrect is that they do not align with the classic signs and symptoms of meningitis, which are mainly related to systemic infection and meningeal irritation.