ATI RN
ATI Capstone Week 11 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1/2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?
Correct Answer: 260
Rationale: The correct answer is 260 mL.
To calculate the child's fluid intake, we need to convert all measurements to mL. 1/2 cup of juice is approximately 120 mL, 3 oz of gelatin is approximately 90 mL, 1 oz of an ice pop is approximately 30 mL, and 20 mL of ginger ale. Adding these amounts together (120 + 90 + 30 + 20) gives a total of 260 mL. This is the total fluid intake the nurse should record for the child. Other choices are incorrect because they do not accurately reflect the total fluid intake based on the given measurements.
Question 2 of 5
The nurse assessing a client hospitalized with a diagnosis of hypoparathyroidism notes positive Trousseau's and Chvostek's signs. The nurse determines that these findings most indicate which electrolyte imbalance?
Correct Answer: C
Rationale: The correct answer is C: Hypocalcemia. Trousseau's and Chvostek's signs are classic manifestations of hypocalcemia. Trousseau's sign is the carpal spasm induced by inflating a blood pressure cuff above systolic pressure, indicating neuromuscular irritability. Chvostek's sign is facial muscle spasm elicited by tapping the facial nerve, also indicative of neuromuscular irritability due to low calcium levels. Hypernatremia (
A), hypermagnesemia (
B), and hypokalemia (
D) do not typically present with these specific signs related to neuromuscular irritability seen in hypocalcemia.
Question 3 of 5
A nurse is caring for a child who has influenza. The nurse should identify which of the following statements by the parent indicates the child has an increased risk for Reye syndrome?
Correct Answer: A
Rationale: The correct answer is A: "I give my child aspirin to reduce his fever." This statement indicates an increased risk for Reye syndrome because aspirin use in children with influenza can lead to Reye syndrome, a rare but serious condition that affects the brain and liver. Reye syndrome is associated with aspirin use in children recovering from viral infections like influenza. Aspirin should be avoided in children with viral illnesses like influenza. The other choices are incorrect because ibuprofen is an appropriate medication for muscle aches, a humidifier can help with congestion, and grapefruit juice does not pose a risk for Reye syndrome.
Question 4 of 5
A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?
Correct Answer: A
Rationale: The correct answer is A: Airway patency. In the postoperative period following a thyroidectomy, airway patency is the priority to monitor due to the risk of airway obstruction from swelling or bleeding. If the airway is compromised, it can lead to serious complications such as respiratory distress or even respiratory arrest. Monitoring airway patency involves assessing for signs of respiratory distress, such as stridor, difficulty breathing, or changes in oxygen saturation. Temperature, pain control, and urination are important to monitor postoperatively, but ensuring the client's airway is clear and functioning properly takes precedence to prevent life-threatening complications.
Question 5 of 5
A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct response is B: The recommendation for you is about 15 to 25 pounds. This is because a client with a BMI of 26.5 falls into the overweight category, and the recommended weight gain during pregnancy for overweight individuals is 15-25 pounds. This range helps in promoting a healthy pregnancy and reducing the risk of complications. Options A and D suggest weight gain ranges that are higher than recommended for an overweight individual, which could lead to potential health risks. Option C states a fixed rate of 1 pound per week, which may not be suitable for everyone and could lead to excessive weight gain.
Therefore, option B is the most appropriate recommendation for a client with a BMI of 26.5.