ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?
Correct Answer: D
Rationale: The correct answer is D: Dorsiflexion of the great toe. Babinski's sign is an abnormal response where the great toe extends and the other toes fan out when the sole of the foot is stroked. In this scenario, a client with an unrepaired femur fracture suddenly becoming stuporous may indicate increased intracranial pressure. Assessing for Babinski's sign helps in detecting neurological abnormalities.
Choices A, B, and C are unrelated to Babinski's sign and are not indicative of neurological issues. Jerking contractions of the head and neck, pinpoint pupils, and pronation of the arms are not specific to Babinski's sign and do not provide relevant information in this situation.
Question 3 of 5
The emergency department nurse is preparing an infusion of IV alteplase for a client who suffered a cerebrovascular accident (CVA). Which of the following statements is accurate about the administration of alteplase?
Correct Answer: B
Rationale: The correct answer is B. Alteplase is administered as a bolus over 1-2 minutes, followed by a continuous infusion over 60 minutes. This rapid administration is crucial for the drug's thrombolytic action to dissolve the clot causing the CVA. Giving it as a bolus over 3 minutes (option
B) is not accurate, as it should be given over a shorter time frame. Option A is incorrect because alteplase can be given to patients on anticoagulant or antiplatelet therapy with caution. Option C is incorrect as the recommended time for administration is within 3 hours of symptom onset, not 90 minutes after admission. Option D is incorrect as the maximum dosage of alteplase is 0.9 mg/kg, not a fixed 120 mg dose.
Question 4 of 5
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Heart rate 160/min. In the compensatory stage of shock, the body attempts to maintain perfusion by increasing heart rate. This is a compensatory mechanism to ensure vital organs receive adequate blood flow. A heart rate of 160/min indicates the body's attempt to maintain cardiac output.
Choices B and C are incorrect as hypokalemia and mottled skin are not specific to the compensatory stage of shock.
Choice D is incorrect because a blood pressure of 115/68 mmHg is within normal range and may not necessarily indicate compensatory shock.
Question 5 of 5
A nurse who is mentoring a graduate nurse explains the correlation between severe blood loss and the effect on the client's mean arterial pressure (MAP). The graduate nurse demonstrates correct understanding when he states which of the following:
Correct Answer: D
Rationale: The correct answer is D: Lower blood volume lowers MAP. Mean Arterial Pressure (MAP) is determined by cardiac output and systemic vascular resistance. Severe blood loss results in decreased blood volume, leading to a decrease in cardiac output. With lower cardiac output, there is less blood being pumped into the arteries, resulting in lower pressure exerted on the arterial walls, hence lowering the MAP.
Choices A and B are incorrect as severe blood loss reduces cardiac output and would not raise it or cause vasoconstriction.
Choice C is incorrect as there is a direct correlation between blood loss and MAP.