ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: Hypovolemia. A low CVP in a client with multiple traumas indicates decreased blood volume, leading to hypovolemia. This can be due to blood loss from trauma. Other choices are incorrect: A (Fluid overload) would result in elevated CVP, C (Left ventricular failure) would typically show an elevated CVP, and D (Intracardiac shunt) would not directly affect CVP. It is crucial for the nurse to recognize hypovolemia promptly in trauma patients to initiate appropriate interventions.
Question 2 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Elevate the head of the bed. This intervention helps to promote venous drainage from the head, reducing intracranial pressure. Elevating the head of the bed also helps to improve cerebral blood flow.
Choices B, C, and D are incorrect. A brightly lit environment can increase stimulation and exacerbate symptoms. Encouraging a high intake of fluids can lead to fluid overload and worsen intracranial pressure. Teaching controlled coughing and deep breathing does not directly address the increased intracranial pressure concern.
Question 3 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.
Question 4 of 5
A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?
Correct Answer: A
Rationale: The correct answer is A: Flexion and internal rotation of upper extremities. Decorticate posturing is characterized by the arms flexing inward towards the core of the body with internal rotation. This occurs due to damage to the corticospinal tracts. Other choices are incorrect because decerebrate posturing (extension and external rotation of upper extremities) is associated with damage to the brainstem. Extension and internal rotation (
Choice
C) and external rotation (
Choice
D) are not typical findings in decorticate posturing.
Question 5 of 5
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?
Correct Answer: D
Rationale: The correct answer is D: Increased heart rate. In hypovolemic shock, the body tries to compensate for decreased blood volume by increasing heart rate to maintain adequate circulation. This is a result of the body's attempt to deliver oxygen and nutrients to vital organs despite the reduced blood volume. The other choices are incorrect because: A: Widening pulse pressure is not typically seen in hypovolemic shock; B: Pulse oximetry of 96% indicates adequate oxygen saturation, not a specific indicator of hypovolemic shock; C: Increased deep tendon reflexes are not typically associated with hypovolemic shock.