ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?
Correct Answer: D
Rationale: The correct answer is D: Decerebrate posturing. The nurse would document this finding by observing the patient's extended arms and legs, rigid posture, and clenched fists, indicating damage to the upper brainstem. Decerebrate posturing is a more severe form of abnormal posturing than decorticate posturing (choice
B), characterized by flexed arms and clenched fists. Spinal cord degeneration (choice
A) refers to progressive damage to the spinal cord, not a specific posture. Atypical hyperreflexia (choice
C) is not a recognized clinical term related to posture.
Therefore, the correct choice is D as it accurately describes the patient's posture and neurological condition.
Question 2 of 5
A nurse cares for a client who is experiencing status epilepticus. Which medication would the nurse prepare for administration?
Correct Answer: A
Rationale: The correct answer is A: Lorazepam. In status epilepticus, immediate treatment is crucial to stop ongoing seizures. Lorazepam is a fast-acting benzodiazepine that helps terminate seizures quickly. It acts by enhancing the effect of GABA, an inhibitory neurotransmitter, leading to sedation and seizure control. Atenolol (
B) is a beta-blocker used for hypertension, not seizures. Phenytoin (
C) and Levetiracetam (
D) are antiepileptic drugs used for long-term seizure management but are not ideal for acute seizure control like in status epilepticus.
Question 3 of 5
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5.3
Rationale:
To calculate the correct dose, we first convert the child's weight from lb to kg: 28 lb / 2.2 = 12.73 kg.
Then, we multiply the weight by the dose (10 mg/kg): 12.73 kg * 10 mg/kg = 127.3 mg. Next, we convert mg to mL using the available concentration: 127.3 mg / 120 mg = 1.06 mL, which rounds to 1 decimal place as 5.3 mL.
Therefore, the nurse should administer 5.3 mL. Other choices are incorrect because they do not follow the correct conversion and calculation steps, leading to inaccurate dosing.
Question 4 of 5
A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for mechanical ventilation. In a myasthenic crisis, respiratory muscles become severely weakened, leading to respiratory failure. Mechanical ventilation is crucial to support breathing and oxygenation. Administering sedatives (choice
A) can further depress respiratory function. Instructing pursed lip breathing (choice
B) may not be sufficient in severe cases. Administering a vasoconstrictor (choice
D) is not indicated in myasthenic crisis.
Question 5 of 5
A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?
Correct Answer: D
Rationale:
Correct Answer: D -
To reduce the risk of stroke in clients who have atrial fibrillation
Rationale:
1. Dabigatran is a direct thrombin inhibitor used as an anticoagulant to prevent blood clots.
2. Atrial fibrillation increases the risk of blood clots forming in the heart, which can lead to strokes.
3. Dabigatran helps by preventing the formation of these blood clots, thus reducing the risk of stroke.
Summary:
A - Incorrect: Dabigatran does not convert atrial fibrillation to sinus rhythm. It is used for stroke prevention.
B - Incorrect: Dabigatran does not dissolve existing clots but prevents new ones from forming.
C - Incorrect: Dabigatran does not directly affect the response of the ventricles to atrial impulses. Its main purpose is stroke prevention.