ATI RN
ATI Capstone Week 9 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: Keeping the drainage system below the level of the client's chest prevents the backflow of air or fluid into the client's chest, ensuring proper functioning of the chest tube. This positioning maintains the integrity of the closed drainage system and prevents complications such as pneumothorax or hemothorax.
Summary of other choices:
B: Clamping the chest tube can lead to a buildup of pressure in the chest, causing potential harm to the client.
C: Disconnecting the chest tube can result in air entering the pleural space, increasing the risk of pneumothorax.
D: Emptying the collection chamber is not necessary prior to transport as it does not affect the function of the chest tube.
Question 2 of 5
A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps.)
Correct Answer: A,B,E,C,D,F
Rationale: Action to Take: Inhale deeply and then exhale completely, Place her lips firmly around the mouthpiece, Breathe in deeply over 2 to 3 seconds while pushing down on the canister, Hold her breath for 10 seconds, Exhale slowly through pursed lips, Wait 60 seconds between each puff; Potential Condition: Asthma; Parameter to Monitor: Inhalation technique, Breath holding duration.
Rationale: The correct sequence ensures optimal delivery of medication. Inhaling deeply allows the medication to reach the lungs. Placing lips firmly ensures a good seal. Breathing in slowly while pushing down delivers the medication. Holding breath allows absorption. Exhaling slowly reduces irritation. Waiting between puffs prevents overdose. Asthma requires careful monitoring of inhalation technique and breath holding for effectiveness and safety.
Question 3 of 5
What information would the nurse include when educating a postsurgical client on the proper use of antiembolism stockings? (Select all that apply)
Correct Answer: A,C,D,E
Rationale: A: Correct. Educating the client on the impairment to blood flow if the stockings are too tight is crucial to prevent complications like impaired circulation or pressure ulcers.
C: Correct. Ensuring skin hygiene and assessment each time the stockings are removed helps in early detection of any skin issues or irritations.
D: Correct. Wearing the stockings both in and out of bed promotes continuous prevention of blood clots, especially during periods of immobility.
E: Correct. Measuring the length and circumference of the leg ensures proper fit, which is essential for the stockings to be effective.
Incorrect choices: B is incorrect as the stockings should be worn continuously, not removed daily for 30 minutes.
Question 4 of 5
A nurse is assessing a client who has thyrotoxicosis after taking too high of a level of levothyroxine. Which of the following manifestations should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Heat intolerance. Thyrotoxicosis, caused by excessive levothyroxine intake, results in excessive thyroid hormone levels leading to increased metabolism. This increased metabolism causes the body to produce excess heat, resulting in heat intolerance. Drowsiness (
A) is not a typical manifestation of thyrotoxicosis; instead, patients may experience insomnia or restlessness due to hyperactivity. Bradycardia (
C) is a manifestation of hypothyroidism, the opposite condition of thyrotoxicosis. Dry skin (
D) is also a manifestation of hypothyroidism due to decreased metabolic activity.
Question 5 of 5
A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Teach the parents about cortisol replacement therapy. In Addison's disease, the adrenal glands do not produce enough cortisol. Cortisol replacement therapy is crucial to manage the condition. By educating the parents about this therapy, they can understand the importance of adherence and monitoring for signs of over or under-replacement.
A: Placing the child on a low-sodium diet is not directly related to managing Addison's disease.
B: Monitoring for fluid volume excess is more relevant in conditions like Cushing's syndrome, not Addison's disease.
C: Hyperglycemia is not a primary manifestation of Addison's disease, so discussing it with the parents is not the priority.
In summary, the correct answer addresses the primary treatment for Addison's disease, while the other options are not directly related to managing this condition.