ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Measure the client's apical pulse. This is crucial before administering digoxin because it helps monitor the client's heart rate, as digoxin can cause bradycardia or dysrhythmias. Monitoring the apical pulse ensures the heart rate is within the safe range for administering the medication.
The other choices are incorrect because:
B: Measuring the client's blood pressure is not specifically necessary before administering digoxin, as the primary concern is monitoring the heart rate.
C: Offering the client a light snack is irrelevant to the administration of digoxin and does not impact the medication's effectiveness or safety.
D: Weighing the client is not directly related to administering digoxin and does not provide information necessary for ensuring safe administration.
Question 2 of 5
A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Speak to the client about one idea at a time. Global aphasia impairs the ability to understand and communicate effectively. By speaking about one idea at a time, the nurse helps the client focus and process information easier. This approach reduces confusion and frustration for the client.
Choice A is incorrect because multitasking can overwhelm someone with global aphasia.
Choice C is incorrect as using multiple forms of communication may be too challenging.
Choice D is incorrect as limiting questions to yes and no may not address the client's needs fully.
Question 3 of 5
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: Hypovolemia. A low CVP in a client with multiple traumas indicates decreased blood volume, leading to hypovolemia. This can be due to blood loss from trauma. Other choices are incorrect: A (Fluid overload) would result in elevated CVP, C (Left ventricular failure) would typically show an elevated CVP, and D (Intracardiac shunt) would not directly affect CVP. It is crucial for the nurse to recognize hypovolemia promptly in trauma patients to initiate appropriate interventions.
Question 4 of 5
A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?
Correct Answer: A
Rationale: The correct answer is A: Ability to self-feed with the use of adaptive equipment. This goal is appropriate because a client with a spinal cord transection at the level of C5 typically has impaired hand function but retains some shoulder and elbow movement. Self-feeding is a basic activity of daily living that can enhance the client's independence and quality of life. Options B and C require higher levels of upper extremity function, which are usually impaired in a client with a C5 spinal cord injury. Option D involves autonomic nervous system functions that are controlled by segments below the level of the injury and are not typically affected by a C5 transection.
Question 5 of 5
What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: The correct signs and symptoms for meningitis include fever and chills due to systemic infection, nuchal rigidity from meningeal irritation, severe headache from increased intracranial pressure, and Brudzinski's sign, which indicates meningeal irritation when the neck is flexed. Bradycardia is not a typical sign of meningitis. The summary of why the other choices are incorrect is that they do not align with the classic signs and symptoms of meningitis, which are mainly related to systemic infection and meningeal irritation.