ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 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 2 of 5
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client’s lung has re-expanded?
Correct Answer: C
Rationale: The correct answer is C: No fluctuations in the water seal chamber. This indicates that the client's lung has re-expanded because there is no longer any air leaking from the pleural space into the chest tube drainage system. Fluctuations in the water seal chamber typically indicate that there is still air escaping from the lung, suggesting ongoing lung collapse or a leak in the system.
Choices A, B, and D do not directly indicate lung re-expansion and are more related to oxygenation, drainage system integrity, or pain management.
Question 3 of 5
A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Decrease the infusion rate. Flushing of the neck and tachycardia are signs of red man syndrome, a common adverse reaction to vancomycin. Decreasing the infusion rate can help minimize the severity of the reaction. Changing the IV site or applying cold compresses are not appropriate interventions for this specific reaction. Documenting an anaphylactic reaction without confirmation is premature and can lead to misinformation in the client's medical record.
Question 4 of 5
A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Focus on providing care that prevents life-threatening emergencies. During a disaster situation with limited staffing, the nurse's priority is to ensure the safety and well-being of the clients. By focusing on providing care that prevents life-threatening emergencies, the nurse can address immediate and critical needs to stabilize and protect clients. This action aligns with disaster protocols, which prioritize the preservation of life.
A: Reinforcing discharge teaching to clients is not a priority during a disaster situation.
B: Instructing assistive personnel to focus on clients' activities of daily living (ADLs) may not address the immediate life-threatening needs of clients during a disaster.
C: Stocking additional unit supplies is important but may not be the immediate priority when dealing with a limited staff during a disaster.
In summary, the nurse should prioritize actions that address preventing life-threatening emergencies to ensure the safety and well-being of clients during a disaster.
Question 5 of 5
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
Correct Answer: B
Rationale: The correct answer is B: Cigarette smoking. Smoking is a modifiable risk factor for cardiovascular disease as individuals can quit smoking to reduce their risk. This is supported by extensive research showing the harmful effects of smoking on the cardiovascular system.
A: Increasing age is a non-modifiable risk factor, as age is a natural process.
C: Family history of cardiac disease is a non-modifiable risk factor, as it is genetic and beyond individual control.
D: Diagnosis of diabetes mellitus is a risk factor, but it is not modifiable. Managing diabetes can reduce the risk of complications but cannot eliminate the underlying condition.