ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
Correct Answer: D
Rationale: The correct answer is D: Lactated Ringers. In the first 24 hours following a burn injury, it is crucial to administer isotonic solutions like Lactated Ringers to replace lost fluids and electrolytes effectively. Lactated Ringers contain electrolytes like sodium, potassium, and chloride, which help maintain proper fluid balance and prevent dehydration. Dextrose 5% in water (
Choice
A) is a hypotonic solution and may lead to fluid shifts, worsening the condition. 0.45% sodium chloride (
Choice
B) is hypotonic and may not provide enough electrolytes for proper fluid replacement. Dextrose 5% in 0.9% sodium chloride (
Choice
C) may not provide adequate electrolytes compared to Lactated Ringers.
Question 2 of 5
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the burn injury. What percentage of body surface area should the nurse estimate?
Correct Answer: D
Rationale: The nurse should estimate the percentage of body surface area affected by the burn injury using the Rule of Nines. According to this rule, specific body areas are assigned percentages: head (9%), each arm (9% total), each leg (18% total), front torso (18%), back torso (18%), and perineum (1%). By adding these percentages, a total of 100% is obtained. For severe burns, the nurse should estimate using the Rule of Nines, making D (8%) the most appropriate choice as it closely aligns with the total percentage of body surface area affected by the burn.
Choices A, B, C, and E do not align with the Rule of Nines and would not accurately estimate the extent of the burn injury.
Question 3 of 5
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. In extensive burn injuries, there is a significant release of potassium from damaged cells, leading to elevated serum potassium levels. This can result in cardiac arrhythmias and other complications. Hypervolemia (
A) is less likely due to fluid shifts, low hemoglobin (
C) is not typically seen in the acute phase of burn injuries, and metabolic alkalosis (
D) is not a common laboratory finding in this scenario.
Question 4 of 5
Select the 5 findings that can cause delayed wound healing.
Correct Answer: A,B,C,D,E
Rationale: The correct answer includes all factors that can contribute to delayed wound healing. A: Diabetes mellitus impairs wound healing due to vascular and neuropathic complications. B: Hyperlipidemia can lead to poor circulation and impair the immune response. C: Wound infection prolongs the inflammatory phase and delays healing. D: Decreased pedal perfusion compromises blood flow necessary for tissue repair. E: Elevated fasting blood glucose levels hinder immune function and collagen synthesis. These factors collectively contribute to delayed wound healing. Other choices are incorrect as they do not directly impact wound healing in the same manner as the selected options.
Question 5 of 5
When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?
Correct Answer: C
Rationale: The correct answer is C: Crackles, peripheral edema, and weight gain. In infective endocarditis, there is a risk of developing heart failure due to damage to the heart valves. Monitoring for crackles indicates fluid accumulation in the lungs, a sign of left-sided heart failure. Peripheral edema is a result of right-sided heart failure, which can occur in infective endocarditis. Weight gain is a common symptom of heart failure due to fluid retention. Flank pain with radiation to the groin and hematuria (choice
A) are more indicative of kidney issues rather than heart failure. Respiratory distress, chest pain, and use of accessory muscles (choice
B) are more suggestive of acute pulmonary conditions. Confusion, decreasing level of consciousness, and aphasia (choice
D) are symptoms of neurological issues, not heart failure.