ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
Correct Answer: C
Rationale: The correct answer is C: Atelectasis. A lacerated spleen can lead to splenic embolization, causing atelectasis due to the accumulation of blood or fluid in the pleural space. This results in decreased breath sounds in the affected lobes. Pulmonary edema (
A) would present with crackles, not decreased breath sounds. An upper respiratory infection (
B) typically presents with upper respiratory symptoms like cough and congestion, not decreased breath sounds. Delayed gastric emptying (
D) is unrelated to the respiratory system.
Question 2 of 5
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Test the drainage for glucose. This is the first action the nurse should take because clear drainage from the nose following a basal skull fracture may indicate a cerebrospinal fluid (CSF) leak. Testing the drainage for glucose can help differentiate between CSF and other types of nasal discharge. If the drainage tests positive for glucose, it confirms the presence of CSF. This finding is crucial for determining the appropriate management and potential complications associated with a CSF leak.
Summary of other choices:
A: Asking the client to blow his nose is not appropriate as it can increase intracranial pressure.
B: Suctioning the nostril can worsen the CSF leak and should be avoided.
C: Notifying the physician is important, but testing the drainage for glucose should be done first.
E, F, G: No additional options provided, but none would be more appropriate than testing the drainage for glucose.
Question 3 of 5
A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Infuse the medication with an IV pump. Theophylline requires precise dosing and continuous monitoring due to its narrow therapeutic range. Using an IV pump ensures accurate infusion rate, reducing the risk of medication errors. Administering a test dose (
A) is unnecessary for theophylline. Covering the IV container with dark paper (
C) is not relevant. Infusing the medication at 35 mg/min (
D) may exceed safe limits and cause adverse effects.
Question 4 of 5
A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention?
Correct Answer: B
Rationale: Tertiary prevention focuses on managing and treating existing conditions to prevent complications and further deterioration. Providing treatment for clients with chronic obstructive pulmonary disease aligns with this level by aiming to minimize the impact of the disease and prevent exacerbations. Testing new nurses for exposure to tuberculosis (
A) is an example of primary prevention as it aims to prevent the initial occurrence of the disease. Performing screening for sexually transmitted infections (
C) falls under secondary prevention, which aims to detect and treat diseases in early stages. Administering influenza immunizations (
D) is considered primary prevention as it aims to prevent the occurrence of influenza.
Question 5 of 5
A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?
Correct Answer: D
Rationale: The correct answer is D: Systolic blood pressure changed from 140 mm Hg to 110 mm Hg. This finding should be reported to the provider because it indicates a significant decrease in blood pressure, which could be a sign of hypotension or other cardiovascular complications post-surgery. Hypotension can lead to decreased perfusion to vital organs and tissues, potentially causing serious complications. The other choices (A, B, and
C) involve changes that are within a normal range for a postoperative patient and do not pose immediate risks to the client's well-being. Reporting the correct finding promptly allows for timely intervention and prevents further complications.