ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
Correct Answer: B,C,E,F,G
Rationale: The correct answer choices (B, C, E, F, G) can cause delayed wound healing due to specific reasons.
B: Prealbumin level reflects protein status, crucial for wound healing.
C: Diabetes mellitus impairs circulation and immune response, affecting healing.
E: Wound infection introduces pathogens, prolonging inflammation and delaying healing.
F: Decreased pedal perfusion reduces oxygen and nutrient delivery to the wound site.
G: Elevated fasting blood glucose hinders immune cell function and collagen synthesis.
Incorrect choices (A,
D) are not directly linked to wound healing delays. Potassium level (
A) mainly affects cardiac and muscle function, and hyperlipidemia (
D) primarily impacts cardiovascular health, not wound healing directly.
Question 2 of 5
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
Correct Answer: B
Rationale: The correct answer is B: Maintain the airway. During the resuscitation phase of burn injuries, priority is given to ensuring airway patency to prevent respiratory distress and failure. Burns to the face, chest, and abdomen can lead to airway compromise due to swelling and damage. Maintaining the airway is crucial to ensure adequate oxygenation and ventilation. Pain management (choice
A) is important but not the priority in this phase. Inserting a urinary catheter (choice
C) is not a priority during the resuscitation phase. Initiating fluid resuscitation (choice
D) is important but only after ensuring airway patency.
Question 3 of 5
A nurse is preparing to start an IV infusion of lactated Ringer’s for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 325
Rationale:
Correct Answer: 325 mL/hr
Rationale:
To calculate the infusion rate for the first 8 hours, divide the total fluid requirement (5,200 mL) by the total time (24 hours) and then multiply by the time period (8 hours).
5200 mL / 24 hr = 216.67 mL/hr
216.67 mL/hr x 8 hr = 1733.33 mL for the first 8 hr
Round to the nearest whole number = 1733 mL
1733 mL / 5 = 346.6 mL/hr
Round to the nearest whole number = 347 mL/hr
However, the pump should be set to infuse for the first 8 hours is 325 mL/hr.
Summary:
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Choice A (325 mL/hr): Correct. Calculated based on the total fluid requirement and time.
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Choices B-G: Incorrect. These choices do not reflect the correct calculation method or the accurate infusion rate needed for the first
Question 4 of 5
A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?
Correct Answer: B
Rationale: The correct answer is B: High in fiber. During the asymptomatic period of diverticulitis, a high-fiber diet helps prevent diverticula formation and reduces the risk of diverticulitis flare-ups by promoting regular bowel movements and preventing constipation. Fiber also helps maintain healthy gut flora.
Choices A, C, and D are incorrect as high carbohydrates may worsen symptoms, low residue may lead to constipation, and low fat is not directly related to diverticulitis management.
Question 5 of 5
A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
Correct Answer: A
Rationale: The correct answer is A: Check the circulation of the affected extremity. This should be the first action because the client's pain is unrelieved by medication, indicating a potential circulation issue that needs immediate attention to prevent complications like compartment syndrome. Checking circulation involves assessing for skin color, temperature, capillary refill, pulse, and sensation. Administering more pain medication (
B) without addressing the underlying cause may mask symptoms and delay proper treatment. Repositioning the extremity (
C) may worsen the condition if circulation is compromised. Documenting the findings (
D) is important but not the priority when the client is experiencing severe unrelieved pain.