ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
Correct Answer: C
Rationale:
Rationale:
The correct answer is C:
To prevent drainage from accumulating in the wound. A Jackson-Pratt drain is used to remove excess fluids (such as blood or serous fluid) from a surgical site to prevent accumulation, which can lead to infection or delayed healing. The drain creates negative pressure, allowing drainage to be collected in a bulb or reservoir outside the body. This promotes wound healing by preventing the buildup of fluid.
Incorrect choices:
A:
To limit bleeding - While a JP drain may indirectly help limit bleeding by removing excess fluid, its primary purpose is to prevent fluid accumulation.
B:
To eliminate wound irrigations - JP drains do not eliminate the need for wound irrigations; they are used for drainage removal.
D: Medication administration - JP drains do not provide a means for medication administration; they are specifically for drainage removal.
Question 2 of 5
The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)
Correct Answer: B,D,E
Rationale: The correct manifestations correlating with a digoxin level of 2.3 ng/dL are Nausea, Seeing halos around bright objects, and Photophobia. Nausea is a common side effect of digoxin toxicity. Seeing halos around bright objects is a sign of visual disturbances associated with digoxin toxicity. Photophobia is sensitivity to light, which can occur with digoxin toxicity. Increased appetite and energy levels are not typically associated with digoxin toxicity and are therefore incorrect choices.
Question 3 of 5
A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
Correct Answer: C
Rationale:
Rationale:
The correct answer is C:
To prevent drainage from accumulating in the wound. A Jackson-Pratt drain is used to remove excess fluids (such as blood or serous fluid) from a surgical site to prevent accumulation, which can lead to infection or delayed healing. The drain creates negative pressure, allowing drainage to be collected in a bulb or reservoir outside the body. This promotes wound healing by preventing the buildup of fluid.
Incorrect choices:
A:
To limit bleeding - While a JP drain may indirectly help limit bleeding by removing excess fluid, its primary purpose is to prevent fluid accumulation.
B:
To eliminate wound irrigations - JP drains do not eliminate the need for wound irrigations; they are used for drainage removal.
D: Medication administration - JP drains do not provide a means for medication administration; they are specifically for drainage removal.
Question 4 of 5
A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Fat embolism. Fat embolism can occur in clients with long bone fractures, like a femoral head fracture. Fat emboli can travel to the lungs leading to respiratory distress, shortness of breath, and dyspnea. This is a potential complication that can occur within the first 24-48 hours post-injury. Fat embolism is characterized by respiratory symptoms and can lead to hypoxia and respiratory failure.
Other choices are incorrect because:
A: Airway obstruction typically presents with choking or difficulty swallowing, not specifically with shortness of breath and dyspnea.
B: Pneumonia would typically present with fever, productive cough, and chest pain, not sudden-onset shortness of breath.
C: Pneumothorax presents with sudden chest pain and shortness of breath due to air in the pleural space, not directly related to a femoral head fracture.
Overall, the key to this question is
Question 5 of 5
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.
Correct Answer: 72
Rationale: The Rule of Nines is a method used to estimate the total body surface area (TBS
A) burned in a patient with severe burns. According to this rule, each major body part represents a specific percentage of the TBSA. In an adult, the head accounts for 9%, each upper extremity is 9% (18% total), the front of the trunk is 18%, the back of the trunk is 18%, each lower extremity is 18% (36% total), and the genital area is 1%.
Therefore, if a client has sustained severe burn injuries in a grease fire, the nurse should estimate that the client has burned approximately 72% of their TBSA. This calculation is crucial in determining the severity of the burns and guiding appropriate treatment. The correct answer is 72 because it reflects the accurate estimation of the TBSA burned using the Rule of Nines. The other choices are incorrect as they do not align with the standard percentages