ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
Correct Answer: C
Rationale:
Correct Answer: C. Pacemaker spikes before each QRS complex.
Rationale: In a client with a ventricular pacemaker, the pacemaker spike should precede the QRS complex since the pacemaker is responsible for initiating the electrical impulse to stimulate ventricular depolarization. This is known as ventricular pacing. The presence of the pacemaker spike before each QRS complex indicates proper functioning of the pacemaker and effective capture of the ventricles. This ensures that the heart is being paced appropriately, maintaining the heart rate and rhythm.
Summary:
A: Pacemaker spikes with each T wave - Incorrect. Pacemaker spikes should precede QRS complex, not T wave.
B: Pacemaker spikes before each P wave - Incorrect. Ventricular pacemakers are responsible for pacing the ventricles, not atria.
D: Pacemaker spikes after each QRS complex - Incorrect. Pacemaker spikes should precede QRS complex for effective pacing.
Question 2 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 3 of 5
A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Measure the client's apical pulse. This is crucial before administering digoxin because it helps monitor the client's heart rate, as digoxin can cause bradycardia or dysrhythmias. Monitoring the apical pulse ensures the heart rate is within the safe range for administering the medication.
The other choices are incorrect because:
B: Measuring the client's blood pressure is not specifically necessary before administering digoxin, as the primary concern is monitoring the heart rate.
C: Offering the client a light snack is irrelevant to the administration of digoxin and does not impact the medication's effectiveness or safety.
D: Weighing the client is not directly related to administering digoxin and does not provide information necessary for ensuring safe administration.
Extract:
Progress Notes
Day 1
Client presents with abrupt onset of stroke-like manifestations with right facial droop, slurred speech, ataxia, and decrease in level of consciousness.
CT scan indicates ischemic stroke. Thrombolytic therapy with alteplase 90 mg IV over 1 hr given without incident.
Day 2
Client alert and oriented to person, place, and time; speech slightly slurred, but comprehendible. Smile asymmetrical, right side of mouth drooping. Weakness to right arm and leg. Muscle strength with unequal grips, right hand weaker, muscle strength to right leg weaker. Swallow study reports reviewed.
Day 3
Client to be discharged with prescriptions for home health including speech, physical, and occupational therapy.
Client instructed on lifestyle changes to decrease stroke risk including medication therapy for atrial fibrillation, hypertension, hyperlipidemia. Client instructed on Level 3 dysphagia diet, as well as safe practices during mealtimes. On this diet the client can eat bite-sized pieces of moist foods with near- normal textures. They should avoid very hard, sticky, or crunchy foods, such as dried fruit or nuts.
Medical History
Atrial fibrillation Hypertension Obesity Hyperlipidemia
Diagnostic Results
Day 1
CT Scan:
Non-contrast CT of client who presents with facial droop, ataxia, and decrease in level of consciousness. No evidence of acute bleeding or lesions. Slight loss of normal gray matter/white matter differentiation may indicate early ischemic changes consistent with acute infarction.
Day 2
Swallow study.
Swallow study co texture. Results it
Question 4 of 5
A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Correct Answer: B,C,E,F
Rationale:
Correct Answer: B, C, E, F
Rationale:
B: Stopping watching TV while eating promotes mindful eating, aiding in digestion.
C: Having food consistency of pudding may be required for easier swallowing post-discharge.
E: Not drinking liquids with food prevents choking risk and aids digestion.
F: Avoiding nuts can prevent choking, especially if the client has swallowing difficulties.
Summary of Incorrect
Choices:
A: Looking up at the ceiling during swallowing is incorrect as it can lead to aspiration.
D: Having cream soups may not be suitable for certain conditions and can cause swallowing issues.
G: Incomplete information provided.
Extract:
Question 5 of 5
A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?
Correct Answer: C
Rationale:
Rationale: Guillain-Barré syndrome affects the peripheral nervous system, potentially leading to autonomic dysfunction causing neurogenic shock. This client is at risk due to nerve damage affecting blood vessel tone regulation. Chronic kidney disease (
A) is not directly related to neurogenic shock. Asthma (
B) does not typically lead to neurogenic shock. Severe burn injury (
D) can cause hypovolemic shock, not neurogenic shock. Other choices (E, F, G) are not provided.