ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)
Correct Answer: A,B,C,E
Rationale: The correct actions are A, B, C, and E.
A) Providing diversionary activities can distract the client from pulling on the NG tube.
B) Assisting with toileting at frequent intervals helps address any discomfort or restlessness that may be contributing to the behavior.
C) Involving the family can provide additional support and understanding of the client's needs. E) Using an electronic bed alarm device can alert the nurse when the client is attempting to pull on the NG tube, allowing for timely intervention. These actions focus on addressing the underlying reasons for the behavior and ensuring the client's safety without resorting to restraints, which should be a last resort due to ethical and legal considerations.
Question 2 of 5
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.
Correct Answer: 72
Rationale: The Rule of Nines is a method used to estimate the total body surface area (TBS
A) burned in a patient with severe burns. According to this rule, each major body part represents a specific percentage of the TBSA. In an adult, the head accounts for 9%, each upper extremity is 9% (18% total), the front of the trunk is 18%, the back of the trunk is 18%, each lower extremity is 18% (36% total), and the genital area is 1%.
Therefore, if a client has sustained severe burn injuries in a grease fire, the nurse should estimate that the client has burned approximately 72% of their TBSA. This calculation is crucial in determining the severity of the burns and guiding appropriate treatment. The correct answer is 72 because it reflects the accurate estimation of the TBSA burned using the Rule of Nines. The other choices are incorrect as they do not align with the standard percentages
Question 3 of 5
A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
Correct Answer: C
Rationale: The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice
A) or completing a head-to-toe assessment (choice
D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice
B) may provide important information but is not as urgent as assessing vital signs in this critical situation.
Question 4 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?
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 5 of 5
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them.
Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep.
Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.