ATI RN
ATI Capstone Week 9 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?
Correct Answer: A
Rationale: The correct answer is A: Auscultate the site for a bruit. This technique is used to assess the patency of an AV graft by listening for the characteristic "swishing" sound created by blood flow through the graft. A bruit indicates good blood flow, suggesting the graft is patent.
Choice B is incorrect because blood pressure comparison between the arms is not a reliable method for assessing AV graft patency.
Choice C is incorrect because using a Doppler to auscultate the antecubital fossa does not specifically assess the patency of the AV graft.
Choice D is incorrect because checking the brachial and radial pulses simultaneously does not provide direct information about the patency of the AV graft.
Overall, auscultating the site for a bruit is the most specific and direct method for assessing the patency of an AV graft.
Extract:
Nurses' Notes
Day 1:
1000:
Client alert and oriented x3. Lung fields clear, heart rhythm regular bowel sounds normoactive x4; ate 75% of morning meal. Denies pain. Left forearm arteriovenous (AV) fistula, skin warm, brachial and radial pulses 2+
1600:
Client returned from dialysis, lethargic, not hungry, tried to eat a few crackers but vomited them up. Capillary blood glucose 134 mg/dL. AV fistula site skin warm, bruit and thrill noted, brachial and radial pulses palpable.
Day 2:
0700:
Client reports not sleeping well last night; capillary blood glucose 75 mg/dL; crackles in left lower lobe: unproductive cough: AV fistula site ecchymotic, warm, bruit and thrill noted. Oriented to person, place, and time.
A nurse is caring for a client receiving hemodialysis.
Vital Signs
Nurses' NotesVital SignsMedical History
Day 1:
1000:
Temperature 36.3°C (97.3°F)
Heart rate 70/min
Respiratory rate 16/min
Blood pressure 144/72 mm Hg
Oxygen saturation 94% on room air
Weight 90 kg (198 lb)
1600:
Temperature 37.1 °C (98.7°F)
Heart rate 62/min
Respiratory rate 16/min
Blood pressure 112/54 mm Hg
Oxygen saturation 95% on room air
Day 2:
0700:
Temperature 36.7°C (98.1°F)
Heart rate 62/min
Respiratory rate 12/min
Blood pressure 118/52 mmHg
Oxygen saturation 95% on room air
Weight 86.4 kg (190)
A nurse is caring for a client receiving hemodialysis.
Medical History
Nurses' NotesVital SignsMedical History
Client has a history of type 2 diabetes mellitus, and hemodialysis with Arteriovenous fistula.
A nurse is caring for a client receiving hemodialysis.
Question 2 of 5
A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up?
Correct Answer: B,E,F
Rationale: The correct answer is B, E, and F. Weight monitoring is crucial in patients receiving hemodialysis due to fluid shifts. Changes in lung sounds can indicate fluid overload or pulmonary edema. Assessing the AV fistula site is important to ensure patency and prevent infection. Vital signs are typically monitored during hemodialysis sessions and should be stable. Blood glucose levels are not directly impacted by hemodialysis. Presence of bruit and thrill at the fistula site is a normal finding indicating good blood flow.
Extract:
Question 3 of 5
A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?
Correct Answer: B
Rationale: The correct answer is B: Weight gain. In hypothyroidism, the metabolic rate decreases, leading to a reduced ability to burn calories, thus causing weight gain. Exophthalmos (
A) is a sign of hyperthyroidism, not hypothyroidism. Diaphoresis (
C) refers to excessive sweating, which is not typically associated with hypothyroidism. Palpitations (
D) are more commonly seen in hyperthyroidism due to an increased heart rate.
Question 4 of 5
A nurse is preparing a client for a kidney biopsy. Which of the following client conditions should the nurse identify as a contraindication for this diagnostic test?
Correct Answer: C
Rationale: The correct answer is C: Coagulation disorder. A kidney biopsy involves inserting a needle into the kidney to obtain a tissue sample. If a client has a coagulation disorder, there is an increased risk of excessive bleeding during the procedure. This could lead to serious complications such as hemorrhage.
Flank pain (
A) is a common symptom in kidney conditions but is not a contraindication for a kidney biopsy. Elevated creatinine level (
B) may indicate kidney dysfunction but is not a direct contraindication for the procedure. Urinary retention (
D) does not directly affect the safety of a kidney biopsy.
Question 5 of 5
A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?
Correct Answer: A
Rationale: The correct answer is A: Auscultate the site for a bruit. This technique is used to assess the patency of an AV graft by listening for the characteristic "swishing" sound created by blood flow through the graft. A bruit indicates good blood flow, suggesting the graft is patent.
Choice B is incorrect because blood pressure comparison between the arms is not a reliable method for assessing AV graft patency.
Choice C is incorrect because using a Doppler to auscultate the antecubital fossa does not specifically assess the patency of the AV graft.
Choice D is incorrect because checking the brachial and radial pulses simultaneously does not provide direct information about the patency of the AV graft.
Overall, auscultating the site for a bruit is the most specific and direct method for assessing the patency of an AV graft.