ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?
Correct Answer: A
Rationale: The correct answer is A: Elective cardioversion. In this scenario, the client is stable, so immediate interventions like CPR or defibrillation are not necessary. Elective cardioversion is the appropriate action for ventricular tachycardia to restore the heart's normal rhythm. Radiofrequency catheter ablation is a treatment option for arrhythmias but is not typically the first-line intervention for stable VT. Defibrillation is used for unstable VT or ventricular fibrillation. In summary, elective cardioversion is the most appropriate intervention for stable VT in this client.
Extract:
Nurses' Notes
0800:
Client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs continues. Yellow, watery emesis approximately 45 mL on gown; 2 to 5-second-long periods of apnea.
Vital Signs
1002:
Heart rate 86/min Respiratory rate 12/min
Oxygen saturation 86% on room air
Question 2 of 5
A nurse is caring for a client who has a seizure disorder. (Select all that apply.)
Correct Answer: A,C,E
Rationale:
Correct Answer: A, C, E
Rationale:
A: Administering supplemental oxygen helps maintain oxygen levels during a seizure, preventing hypoxia.
C: Timing the seizure duration is crucial for accurate documentation and evaluating the effectiveness of interventions.
E: Turning the client to the side helps prevent aspiration and ensures the airway remains clear.
Incorrect
Choices:
B: Restraining the client during a seizure can cause harm and increase the risk of injury.
D: Placing a tongue depressor in the client's mouth can lead to airway obstruction and injury.
In summary, administering oxygen, timing the seizure, and turning the client are essential interventions, while restraining and using tongue depressors are potentially harmful actions.
Extract:
Question 3 of 5
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Correct Answer: B
Rationale: The correct answer is B: Increased respiratory rate. This is the earliest indicator of shock because the body initially compensates by increasing respiratory rate to improve oxygenation and perfusion. Hypotension (
A) occurs later in shock as a result of decreased cardiac output. Anuria (
C) is a late sign of shock indicating renal failure. Decreased level of consciousness (
D) occurs when brain perfusion is severely compromised.
Therefore, increased respiratory rate is the first sign of the body's attempt to compensate for decreased perfusion in shock.
Question 4 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 5 of 5
A client arrives to the emergency department by ambulance. The client has a possible traumatic brain injury after a fall from a roof. Which of the following assessment findings will the triage nurse report to the provider immediately?
Correct Answer: B
Rationale: The correct answer is B: Decreasing level of consciousness. This would be reported immediately because it indicates a worsening condition and potential deterioration in the client's neurological status. It suggests increased intracranial pressure, which is a medical emergency requiring prompt intervention to prevent further brain injury.
Choices A, C, and D do not indicate an immediate threat to the client's life or neurological status. A pupil response (choice
A) within normal limits, a temporal headache (choice
C), and a Glasgow coma score of 13 (choice
D) are concerning but do not signify an acute decline in neurological status that necessitates immediate action.