ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?
Correct Answer: A
Rationale: The correct answer is A: Dilated scalp veins. In hydrocephalus, there is an accumulation of cerebrospinal fluid within the brain ventricles, leading to increased intracranial pressure. This pressure can cause dilation of scalp veins as a compensatory mechanism to help drain excess fluid. Overriding suture lines (
B) are associated with craniosynostosis, not hydrocephalus. Hypertension (
C) is not a typical manifestation of hydrocephalus. A backward sloping appearance of the forehead (
D) is seen in some genetic conditions like Down syndrome, not specifically in hydrocephalus.
Question 2 of 5
A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A. Using handrails in the bathroom promotes safety by providing support and stability, reducing the risk of falls. This indicates an understanding of fall prevention.
Choice B about a longer telephone cord is unrelated to fall prevention.
Choice C increases the risk of tripping over cords.
Choice D suggests using chairs without armrests can affect stability and increase the risk of falls.
Question 3 of 5
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Test the drainage for glucose. This is the first action the nurse should take because clear drainage from the nose following a basal skull fracture may indicate a cerebrospinal fluid (CSF) leak. Testing the drainage for glucose can help differentiate between CSF and other types of nasal discharge. If the drainage tests positive for glucose, it confirms the presence of CSF. This finding is crucial for determining the appropriate management and potential complications associated with a CSF leak.
Summary of other choices:
A: Asking the client to blow his nose is not appropriate as it can increase intracranial pressure.
B: Suctioning the nostril can worsen the CSF leak and should be avoided.
C: Notifying the physician is important, but testing the drainage for glucose should be done first.
E, F, G: No additional options provided, but none would be more appropriate than testing the drainage for glucose.
Question 4 of 5
A nurse is planning on teaching a client who is scheduled for an IVP. Which of the following statements should the nurse include in the teaching?
Correct Answer: D
Rationale: The correct answer is D: After the procedure, you will be encouraged to drink plenty of fluids. This is important because after an Intravenous Pyelogram (IVP), the contrast dye used can be nephrotoxic, and increasing fluid intake helps to flush out the dye and prevent kidney damage. Encouraging the client to drink plenty of fluids will help protect their kidneys.
Choice A is incorrect because the presence of red blood cells in the urinalysis is not a contraindication for an IVP.
Choice B is incorrect because the client may need to follow specific dietary restrictions before and after the test.
Choice C is incorrect because high-frequency sound waves are used in ultrasound, not in an IVP.
Question 5 of 5
A nurse is teaching a client who is in her first trimester of pregnancy about over-the-counter medications that are a pregnancy risk category B. Which of the following medications should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Acetaminophen. Acetaminophen is classified as pregnancy risk category B, indicating that it is generally considered safe to use during pregnancy. This is because acetaminophen has been widely studied and has not shown any harmful effects on the developing fetus.
Rationale:
1. Naproxen (
A), Aspirin (
B), and Ibuprofen (
C) are all classified as pregnancy risk category C or D, indicating a higher risk of harm to the fetus. These medications are not recommended during pregnancy due to potential adverse effects on the baby.
2. Acetaminophen (
D) is the safest choice among the options provided as it is commonly recommended for pain relief and fever reduction during pregnancy.
3. It is important to choose medications with a lower risk profile during pregnancy to minimize any potential harm to the developing fetus.
In summary, the nurse should include Acetaminophen in the teaching as it is a pregnancy risk