ATI Capstone Exam | Nurselytic

Extract:

Question 1 of 5

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?

Correct Answer: C

Rationale: The correct answer is C: Cardiac murmur. Endocarditis is an infection of the inner lining of the heart chambers and valves, which can lead to the development of a new murmur due to valve damage or vegetation formation. This can result in turbulent blood flow, causing the murmur. A friction rub (choice
A) is more indicative of pericarditis, intermittent claudication (choice
B) is associated with peripheral arterial disease, and dependent rubor (choice
D) is seen in chronic arterial insufficiency.
Therefore, recognizing a new cardiac murmur in a client with endocarditis is crucial as it can indicate complications such as valve dysfunction or embolic events.

Question 2 of 5

A nurse is preparing to start an IV infusion of lactated Ringer’s for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Your Answer:

Correct Answer: 325

Rationale:
Correct Answer: 325 mL/hr

Rationale:
To calculate the infusion rate for the first 8 hours, divide the total fluid requirement (5,200 mL) by the total time (24 hours) and then multiply by the time period (8 hours).
5200 mL / 24 hr = 216.67 mL/hr
216.67 mL/hr x 8 hr = 1733.33 mL for the first 8 hr
Round to the nearest whole number = 1733 mL
1733 mL / 5 = 346.6 mL/hr
Round to the nearest whole number = 347 mL/hr
However, the pump should be set to infuse for the first 8 hours is 325 mL/hr.

Summary:
-
Choice A (325 mL/hr): Correct. Calculated based on the total fluid requirement and time.
-

Choices B-G: Incorrect. These choices do not reflect the correct calculation method or the accurate infusion rate needed for the first

Question 3 of 5

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

A. Avoid handwashing after eating. B. Avoid foods prepared with tap water. C. Avoid eating meat. D. Avoid covering sores with bandages.

Correct Answer: B

Rationale: The correct answer is B: Avoid foods prepared with tap water. This is important because tap water in certain regions may be contaminated with hepatitis-causing viruses. Avoiding tap water in food preparation reduces the risk of contracting viral hepatitis. Handwashing after eating (
A) is actually recommended for preventing the spread of infections. Avoiding eating meat (
C) is not necessary for preventing viral hepatitis transmission. Covering sores with bandages (
D) is unrelated to the prevention of viral hepatitis.

Question 4 of 5

A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.

A. Potassium level. B. Prealbumin level. C. History of diabetes mellitus. D. History of hyperlipidemia. E. Wound infection. F. Decreased pedal perfusion. G. Fasting blood glucose.

Correct Answer: B,C,E,F,G

Rationale: The correct answer choices (B, C, E, F, G) can cause delayed wound healing due to specific reasons.
B: Prealbumin level reflects protein status, crucial for wound healing.
C: Diabetes mellitus impairs circulation and immune response, affecting healing.
E: Wound infection introduces pathogens, prolonging inflammation and delaying healing.
F: Decreased pedal perfusion reduces oxygen and nutrient delivery to the wound site.
G: Elevated fasting blood glucose hinders immune cell function and collagen synthesis.
Incorrect choices (A,
D) are not directly linked to wound healing delays. Potassium level (
A) mainly affects cardiac and muscle function, and hyperlipidemia (
D) primarily impacts cardiovascular health, not wound healing directly.

Question 5 of 5

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

A. Moist skin. B. Blood in the urine. C. Spider angiomas. D. Tarry stools.

Correct Answer: C

Rationale: The correct answer is C: Spider angiomas. In cirrhosis, the liver is damaged leading to increased pressure in the portal vein. This results in dilated blood vessels on the skin surface known as spider angiomas. This finding is expected due to the liver's inability to process blood effectively.
Choice A (Moist skin) is incorrect as cirrhosis commonly causes dry and itchy skin.
Choice B (Blood in the urine) is incorrect because cirrhosis typically does not directly affect the kidneys.
Choice D (Tarry stools) is incorrect as it is a symptom of gastrointestinal bleeding, which can occur in cirrhosis but is not a specific finding.