ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving positive pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications?
Correct Answer: B,C,D,E
Rationale: The correct interventions are B, C, D, and E. Administering pantoprazole helps prevent stress ulcers common in ventilated clients. Verifying ventilator settings ensures proper oxygenation and ventilation. Elevating the head of the bed minimizes risk of aspiration and ventilator-associated pneumonia. Repositioning the endotracheal tube prevents pressure ulcers and airway injury.
Choice A is incorrect as restraints are not recommended unless absolutely necessary.
Question 2 of 5
A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hours. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute?
Correct Answer: 31
Rationale:
To calculate the flow rate in drops per minute for the infusion of packed RBCs, we first need to determine the total number of drops to be infused over 2 hours.
Step 1: Calculate the total drops in 2 hours:
2 hours = 120 minutes
250 mL x 15 gtts/mL = 3750 drops
3750 drops ÷ 120 minutes = 31.25 drops/minute
Step 2: The correct answer is rounded down to 31 drops per minute as IV infusion sets typically do not allow for fractions of drops.
Summary:
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Choice A: Incorrect. The correct flow rate is not 60 drops per minute as that would be too fast.
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Choices B-G: Irrelevant as they do not follow the calculation process required to determine the correct flow rate.
Question 3 of 5
A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: C
Rationale: Correct answer: C. "I should keep my weight within 10 percent of my ideal weight."
Rationale: Maintaining weight within 10% of the ideal weight can help reduce lower back pain in perimenopausal women. Excess weight can strain the lower back, exacerbating pain. This statement shows an understanding of the importance of weight management in alleviating lower back pain.
Incorrect choices:
A: Wearing heels can worsen lower back pain by altering posture.
B: Sleeping with legs extended straight can strain the lower back.
D: Increasing high potassium foods may benefit overall health but is not directly related to lower back pain in perimenopausal women.
Question 4 of 5
A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Weigh the client daily. This is important because chlorpromazine, an antipsychotic medication, can cause weight gain as a side effect. Daily weighing can help monitor for any significant changes in weight, which may indicate potential metabolic side effects. Monitoring for signs of bleeding (
B) is not directly related to chlorpromazine use. Respiratory monitoring (
C) is not a priority for this medication. Administering an antacid (
D) does not directly relate to the client's safety or medication effectiveness.
Question 5 of 5
A charge nurse is discussing the phases of community response to disaster with nursing staff. Which of the following statements indicates an understanding of the heroic phase of disaster response?
Correct Answer: B
Rationale: The correct answer is B because the heroic phase of disaster response is characterized by personnel willingly working in dangerous conditions to provide assistance. During this phase, individuals display selflessness, courage, and a strong sense of duty to help others in need. This phase typically follows the initial shock of the disaster and precedes the disillusionment phase.
Choices A, C, and D do not specifically describe the heroic phase.
Choice A refers to the recovery phase, where normalcy begins to return.
Choice C describes the exhaustion phase, where responders may experience fatigue.
Choice D refers to the communal support phase, where survivors come together to share their experiences.