ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is caring for a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
Correct Answer: D
Rationale: The correct answer is D: Prepare to administer oxytocic medication. This is the priority nursing intervention because the client is experiencing excessive postpartum bleeding, known as hemorrhage. Oxytocic medication helps to contract the uterus, reducing bleeding. Palpating the client's uterine fundus is important to assess uterine tone, but administering oxytocic medication takes precedence in this urgent situation. Assisting the client on a bedpan to urinate is not the priority as addressing the hemorrhage is more urgent. Increasing fluid intake may be beneficial but does not directly address the hemorrhage.
Question 2 of 5
A nurse is preparing to administer vancomycin 15 mg/kg/day divided equally every 12 hours. The client weighs 198 lb. How many mg should the nurse administer with each dose?
Correct Answer: 675
Rationale:
Correct Answer: 675
Rationale:
1. Convert weight from lb to kg: 198 lb ÷ 2.2 = 90 kg.
2. Calculate total daily dose: 15 mg/kg/day x 90 kg = 1350 mg/day.
3. Divide total daily dose by 2 for equal doses every 12 hours: 1350 mg/2 = 675 mg per dose.
Summary:
A, B, C, D, E, F, G: These options do not follow the correct calculation steps. A, B, C, D, E, F, G are incorrect because they do not consider the weight conversion, total daily dose calculation, and dosage frequency requirements.
Question 3 of 5
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client’s neurovascular status?
Correct Answer: B
Rationale: The correct answer is B: Palpate the femoral pulse. When assessing neurovascular status in a client with an unrepaired femur fracture, palpating the femoral pulse is crucial to determine adequate circulation to the lower limb. Absence of the femoral pulse may indicate compromised blood flow, which is a medical emergency requiring immediate intervention. Monitoring calf for edema (
A) is more related to venous status rather than neurovascular assessment. Measuring thigh circumference (
C) does not directly assess neurovascular status. Instructing the client to wiggle his toes (
D) assesses motor function, not neurovascular status.
Question 4 of 5
A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A. Using handrails in the bathroom promotes safety by providing support and stability, reducing the risk of falls. This indicates an understanding of fall prevention.
Choice B about a longer telephone cord is unrelated to fall prevention.
Choice C increases the risk of tripping over cords.
Choice D suggests using chairs without armrests can affect stability and increase the risk of falls.
Question 5 of 5
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse’s priority?
Correct Answer: D
Rationale: The correct answer is D: Blood pressure 80/56 mm Hg. This finding is the priority because it indicates hypotension, a common side effect of opioid epidural analgesia. Hypotension can lead to decreased placental perfusion and compromise fetal well-being. The other options are less urgent: A slight fever (
A) is common with epidural analgesia, weakness of lower extremities (
B) is an expected side effect, and itching (
C) is a common minor side effect.
Therefore, monitoring and addressing the client's low blood pressure is the priority to prevent potential harm to both the mother and the baby.