ATI RN
ATI Capstone Exam 1 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Obtain a 12-lead ECG. A potassium level of 6.8 mEq/L indicates hyperkalemia, which can lead to serious cardiac arrhythmias.
Therefore, obtaining an ECG is crucial to assess for any potential cardiac abnormalities.
Choice B is incorrect as salt substitutes often contain potassium, exacerbating the issue.
Choice C is incorrect as citrus juices and bananas are high in potassium, which should be avoided in hyperkalemia.
Choice D is incorrect as it focuses on sodium levels, not addressing the immediate concern of hyperkalemia.
Question 2 of 5
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Breasts can be examined in the shower with soapy hands. This instruction is important because warm water and soap help to make the examination more comfortable and easier to detect any abnormalities. By examining the breasts in the shower, the individual can incorporate BSE into their routine without it feeling like a separate task. This method also allows for better coverage and thorough examination of the entire breast tissue.
Choice A is incorrect because using the palm of the hand in a circular motion may not be as effective in detecting lumps compared to using the fingertips.
Choice B is incorrect as breast dimpling or discharge are not normal signs of aging, and should be reported to a healthcare provider.
Choice D is incorrect as performing BSE at specific times in the menstrual cycle is not necessary.
Question 3 of 5
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
Correct Answer: A
Rationale: The correct answer is A: Hemorrhage. Postoperative hemorrhage is a critical complication following a transurethral resection of the prostate due to the rich blood supply in the area. It can lead to hypovolemic shock and requires immediate intervention to prevent further complications. Monitoring for signs of bleeding such as increased heart rate, decreased blood pressure, and decreased urine output is crucial.
B: Infection is an important complication to monitor for but is not as immediately life-threatening as hemorrhage.
C: Urinary retention can occur postoperatively but is not as urgent as hemorrhage.
D: Pain management is important for the client's comfort, but it is not the priority in this situation.
In summary, monitoring for hemorrhage is crucial as it is the most life-threatening complication that requires immediate attention compared to the other options.
Question 4 of 5
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice
A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice
B) and hair loss (choice
C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
Question 5 of 5
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
Correct Answer: C
Rationale: The correct answer is C: Prevent aspiration. This is the priority because with intermaxillary fixation, the client's ability to swallow and protect their airway is compromised. Aspiration can lead to serious complications such as pneumonia. Promoting oral hygiene (
A) can be important but not the priority. Ensuring adequate nutrition (
B) is important but can be addressed once the risk of aspiration has been minimized. Relieving pain (
D) is also important but not the priority over preventing aspiration in this case.