ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Call the prescribing physician and inform her of the client’s serum potassium level results. This action is necessary because the client's potassium level is high (5.2 mEq/L), indicating hyperkalemia. The nurse must communicate this critical information to the physician promptly to prevent potential adverse effects of administering additional potassium. Hyperkalemia can lead to serious cardiac dysrhythmias, muscle weakness, and even cardiac arrest. By informing the physician, the nurse ensures that appropriate adjustments can be made to the client's treatment plan.
Choice A (Call the lab to verify the client’s results) is incorrect because the nurse should act on the abnormal result rather than seeking verification.
Choice B (Omit the KCL dose and document it as not given) is incorrect as it does not address the need for immediate action.
Choice C (Give the ordered KCL as prescribed) is incorrect because administering KCL would worsen the hyperkalemia. The best course
Question 2 of 5
A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A,B,D,E
Rationale:
Correct Answer: A, B, D, E
Rationale:
A: Applying intermittent ice helps reduce inflammation and pain in the initial 48 hours post-injury.
B: Wrapping the ankle with a compression bandage provides support and helps reduce swelling.
D: Elevating the ankle above the heart helps reduce swelling by promoting fluid drainage.
E: Applying heat after 48 hours can help promote blood flow and aid in healing, but should not be used during the acute phase due to potential exacerbation of inflammation.
Incorrect
Choices:
C: Full weight-bearing is not recommended initially as it can worsen the injury.
Summary: The correct instructions focus on reducing swelling and pain, providing support, and promoting healing while avoiding actions that may exacerbate inflammation or worsen the injury.
Question 3 of 5
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client’s neurovascular status?
Correct Answer: B
Rationale: The correct answer is B: Palpate the femoral pulse. When assessing neurovascular status in a client with an unrepaired femur fracture, palpating the femoral pulse is crucial to determine adequate circulation to the lower limb. Absence of the femoral pulse may indicate compromised blood flow, which is a medical emergency requiring immediate intervention. Monitoring calf for edema (
A) is more related to venous status rather than neurovascular assessment. Measuring thigh circumference (
C) does not directly assess neurovascular status. Instructing the client to wiggle his toes (
D) assesses motor function, not neurovascular status.
Question 4 of 5
A nurse is caring for a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements can be expected?
Correct Answer: A
Rationale: The correct answer is A: "I can expect to have swelling in my face." In nephrotic syndrome, there is excessive protein loss in the urine, leading to low protein levels in the blood. This results in decreased colloidal osmotic pressure, leading to fluid shifting into tissues, causing edema, commonly in the face (periorbital edema). This statement aligns with the pathophysiology of nephrotic syndrome.
Choices B, C, and D are incorrect. B is incorrect as protein loss occurs in the urine, not sodium. C is incorrect as clients with nephrotic syndrome often require sodium restriction. D is incorrect as kidney biopsy is not typically indicated for nephrotic syndrome diagnosis.
Question 5 of 5
A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Position the newborn at a 45-degree angle in the car seat. This is important because newborns have limited neck strength and need to be positioned at a reclined angle to keep their airway open and prevent their head from flopping forward, reducing the risk of suffocation. Placing the newborn at a 45-degree angle also helps prevent slumping which can compromise their breathing.
A: Placing the shoulder harness straps below the newborn's armpits can lead to improper positioning and potential injury in case of a crash.
B: Keeping the car seat rear-facing until the newborn can sit unsupported is a general guideline but not specific to the proper angle of positioning.
C: Placing the retainer clip across the newborn's abdomen can cause abdominal injury in a crash and should be positioned at armpit level.
E, F, G: No additional choices provided.