ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of 'tightness' in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?
Correct Answer: B
Rationale: The correct answer is B: Acute hemolytic transfusion reaction. This type of reaction occurs when there is a mismatch between the donor and recipient blood types, leading to the rapid destruction of the infused red blood cells. The symptoms presented by the client, such as chills, headache, low-back pain, and chest tightness, are indicative of a severe immune response causing the release of cytokines and other inflammatory mediators. It is crucial for the nurse to recognize these signs promptly as this reaction can be life-threatening if not addressed immediately.
Other choices are incorrect because:
A: Allergic reactions typically present with symptoms like itching, hives, and mild respiratory distress, not the severe symptoms described in the scenario.
C: Bacterial reactions occur due to contaminated blood products and usually manifest with fever, chills, and hypotension, rather than the specific symptoms mentioned.
D: Febrile nonhemolytic reactions are characterized by fever and chills, without the additional symptoms
Question 2 of 5
A nurse is providing teaching to a group of clients about complementary and alternative therapies using herbs. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale:
Correct Answer: A - "I can use chamomile tea to promote sleep"
Rationale: Chamomile is known for its calming properties and can help promote relaxation and improve sleep quality. This statement shows an understanding of using herbs for specific purposes, aligning with complementary and alternative therapies.
Summary of Incorrect
Choices:
B: Herbal medicines can interact with conventional medications, leading to potential adverse effects.
C: While ginger can help with nausea and inflammation, it is not typically used for headaches.
D: Herbal medicines are not regulated by the FDA, which can lead to variations in quality and safety.
Question 3 of 5
A nurse is preparing to administer heparin at 1,000 units/hr via continuous IV infusion to a client who had a coronary artery bypass graft. Available is heparin 25,000 units in dextrose 5% in water in 250 mL. The nurse should set the IV pump to deliver how many mL/hr?
Correct Answer: 10
Rationale: The correct answer is 10 mL/hr.
To calculate this, first determine the total units in the bag (25,000 units).
Then, divide this by the desired dose rate (1,000 units/hr) to get 25 hours. Next, divide the total volume of the bag (250 mL) by the total time in hours to get 10 mL/hr. This ensures the client receives the correct dose of heparin over the specified time. Other choices are incorrect because they do not follow the correct calculation method or do not result in the precise dosage required for the client's condition.
Question 4 of 5
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Nervousness. A blood glucose level of 64 mg/dL indicates hypoglycemia in a client with type 1 diabetes. Nervousness is a common symptom of hypoglycemia due to the body's stress response to low blood sugar. Tachypnea (choice
A) is more likely to be seen in diabetic ketoacidosis. Ketonuria (choice
B) is a sign of hyperglycemia and ketosis, not hypoglycemia. Warm skin (choice
C) is not specific to any particular blood glucose level.
Therefore, the nurse should expect the client to display nervousness as a result of the low blood glucose level.
Question 5 of 5
A nurse is teaching a client who has major depressive disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client?
Correct Answer: C
Rationale: The correct answer is C: You might feel a bit confused for a few hours after the procedure. This is because confusion is a common side effect of electroconvulsive therapy (ECT) due to the temporary disruption of cognitive functions. The confusion typically resolves within a few hours post-procedure.
Choice A is incorrect because feeling pulsations in the neck is not a typical sensation experienced during ECT.
Choice B is incorrect as the client usually wakes up shortly after the procedure, not 30 minutes later.
Choice D is incorrect as changes in voice are not a common side effect of ECT.