ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Elevate the head of the bed. This intervention helps to promote venous drainage from the head, reducing intracranial pressure. Elevating the head of the bed also helps to improve cerebral blood flow.
Choices B, C, and D are incorrect. A brightly lit environment can increase stimulation and exacerbate symptoms. Encouraging a high intake of fluids can lead to fluid overload and worsen intracranial pressure. Teaching controlled coughing and deep breathing does not directly address the increased intracranial pressure concern.
Question 2 of 5
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?
Correct Answer: D
Rationale: The correct answer is D: Increased heart rate. In hypovolemic shock, the body tries to compensate for decreased blood volume by increasing heart rate to maintain adequate circulation. This is a result of the body's attempt to deliver oxygen and nutrients to vital organs despite the reduced blood volume. The other choices are incorrect because: A: Widening pulse pressure is not typically seen in hypovolemic shock; B: Pulse oximetry of 96% indicates adequate oxygen saturation, not a specific indicator of hypovolemic shock; C: Increased deep tendon reflexes are not typically associated with hypovolemic shock.
Question 3 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Elevate the head of the bed. This intervention helps to promote venous drainage from the head, reducing intracranial pressure. Elevating the head of the bed also helps to improve cerebral blood flow.
Choices B, C, and D are incorrect. A brightly lit environment can increase stimulation and exacerbate symptoms. Encouraging a high intake of fluids can lead to fluid overload and worsen intracranial pressure. Teaching controlled coughing and deep breathing does not directly address the increased intracranial pressure concern.
Question 4 of 5
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?
Correct Answer: B
Rationale: The correct answer is B: Packed RBCs. In hypovolemic shock, there is a significant loss of blood volume leading to decreased oxygen-carrying capacity. Packed RBCs are the most appropriate choice as they directly increase the oxygen-carrying capacity of the blood, helping to improve tissue perfusion and oxygenation. Cryoprecipitates (
A) are used to manage bleeding disorders, not hypovolemic shock. Albumin (
C) is a colloid solution used for volume expansion but does not directly address the decreased oxygen-carrying capacity in hypovolemic shock. Platelets (
D) are used for clotting disorders, not for hypovolemic shock.
Extract:
Medical History
0900:
Client had a left-hemisphere stroke with right-sided arm mild expressive aphasia. Client is able to ambulate with assistance. Client is alert to person and place but is unable to tell the date and time.
Nurses' Notes
1000:
Client is assisted out of bed to chair. Client is sitting upright eating breakfast. Bilateral breath sounds clear and present throughout. Client drools and clears throat when eating. Voice hoarse after swallowing.
1800:
Client coughing frequently. Breath sounds with crackles heard in right upper lobe.
Vital Signs
1000:
Temperature 37.2° C (99° F) Blood pressure 128/76 mm Hg Heart rate 86/min Respirations 18/min
Oxygen saturation 96% on room air
1800:
Temperature 39.6° C (103.3° F) Blood Pressure 118/78 mm Hg Heart Rate 104/min Respiration rate 24/min
Oxygenation saturation 92% on room air
Question 5 of 5
A nurse is caring for a client who has had a stroke. Select the 3 findings that require immediate follow-up.
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Drooling (
A) could indicate difficulty swallowing or airway compromise. A hoarse voice (
D) may suggest vocal cord dysfunction, which could lead to airway obstruction. Elevated temperature (E) could indicate infection, especially concerning in stroke patients. Blood pressure at 180 (
B) is high but not immediately life-threatening. Breath sounds at 1000 (
C) and missing options (F, G) are not directly related to immediate follow-up in this scenario.