ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?
Correct Answer: B
Rationale: The correct answer is B: Reposition the client at least every 2 hours. Repositioning helps to relieve pressure on the ulcer, promoting healing and preventing further damage. This intervention is crucial in managing pressure ulcers. Applying a heat lamp (choice
A) can worsen the ulcer by increasing the risk of tissue damage. Massaging reddened areas with dressing changes (choice
C) can also cause further damage to the fragile skin. Cleaning the wound with hydrogen peroxide (choice
D) can be too harsh and delay the healing process.
Therefore, choice B is the most appropriate intervention for a client with a stage 3 pressure ulcer.
Question 2 of 5
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?
Correct Answer: D
Rationale: The correct answer is D: Nausea and vomiting. Peritonitis is inflammation of the peritoneum, which can occur in peritoneal dialysis. Nausea and vomiting are common symptoms due to irritation of the peritoneum. Increased urinary output (
A) is not a typical manifestation of peritonitis. Hyperactive bowel sounds (
B) are more indicative of gastrointestinal issues, not peritonitis. Bradycardia (
C) is not a common symptom of peritonitis. In summary, nausea and vomiting are key signs of peritonitis, while the other options are not typically associated with this condition.
Question 3 of 5
A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?
Correct Answer: D
Rationale: The correct answer is D: Low-sodium, fluid-restricted diet. In acute glomerulonephritis, the kidneys are unable to effectively remove excess sodium and fluid, leading to edema and reduced urine output. A low-sodium diet helps reduce fluid retention and prevent further edema. Fluid restriction is also crucial to prevent overload.
Choices A, B, and C do not specifically address the primary issue of fluid retention in glomerulonephritis. A low-protein diet is generally recommended in chronic kidney disease, not necessarily in acute glomerulonephritis. A regular diet with no added salt does not adequately address the need for sodium and fluid restriction in this case.
Question 4 of 5
A nurse is caring for a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements can be expected?
Correct Answer: A
Rationale: The correct answer is A: "I can expect to have swelling in my face." In nephrotic syndrome, there is excessive protein loss in the urine, leading to low protein levels in the blood. This results in decreased colloidal osmotic pressure, leading to fluid shifting into tissues, causing edema, commonly in the face (periorbital edema). This statement aligns with the pathophysiology of nephrotic syndrome.
Choices B, C, and D are incorrect. B is incorrect as protein loss occurs in the urine, not sodium. C is incorrect as clients with nephrotic syndrome often require sodium restriction. D is incorrect as kidney biopsy is not typically indicated for nephrotic syndrome diagnosis.
Question 5 of 5
A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Aplastic anemia results from decreased bone marrow production of RBCs. In aplastic anemia, the bone marrow fails to produce enough red blood cells, white blood cells, and platelets. This leads to pancytopenia, a reduction in all blood cell types. Options A, B, and D are incorrect because they do not accurately describe the pathophysiology of aplastic anemia. Increased rate of RBC destruction (
A) is seen in hemolytic anemias, decreased intake of iron (
B) is associated with iron-deficiency anemia, and inability to absorb vitamin B12 (
D) is characteristic of pernicious anemia, not aplastic anemia.