ATI RN
ATI Capstone Week 9 Exam Questions
Extract:
Question 1 of 5
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client's respiratory status. Slow, steady bubbling in the suction control chamber indicates that the system is functioning properly. This bubbling is expected as it shows that the system is maintaining the desired negative pressure. Monitoring the client's respiratory status is essential to ensure that there are no underlying respiratory complications post-thoracotomy.
Option B is incorrect because clamping the chest tube can lead to a tension pneumothorax. Option C is incorrect as checking the suction control outlet on the wall is not necessary in this situation. Option D is incorrect as checking tubing connections for leaks is not indicated when there is slow, steady bubbling. It's crucial to understand the rationale behind each option to make the best clinical decision.
Question 2 of 5
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Check the tubing for kinks. The first step should be to assess for any possible obstructions in the catheter tubing, as a kink may be preventing proper drainage. Checking for kinks is a basic troubleshooting step that can quickly resolve the issue. If a kink is found and corrected, the catheter should begin draining normally. This action is within the nurse's scope of practice and can be done immediately without needing to involve the provider. Adjusting the rate of bladder irrigation (
A) may exacerbate the issue if there is an obstruction. Ambulating the client (
B) is not appropriate until the catheter issue is resolved. Notifying the provider (
C) should be done after assessing and addressing the immediate problem.
Question 3 of 5
A nurse is teaching a client who has diabetes mellitus and a new prescription for glimepiride. The nurse should teach the client to avoid which of the following drinks while taking this medication?
Correct Answer: C
Rationale: The correct answer is C: Alcohol. Glimepiride, a sulfonylurea medication, can cause a disulfiram-like reaction when consumed with alcohol, leading to symptoms like nausea, vomiting, flushing, and rapid heart rate. Coffee (
A) and milk (
B) do not have interactions with glimepiride. Grapefruit juice (
D) can interact with certain medications but not with glimepiride. In summary, alcohol should be avoided due to the potential for a harmful reaction when taken with glimepiride.
Question 4 of 5
A nurse is caring for a client with a pheochromocytoma. Which assessment finding will the nurse expect for this client?
Correct Answer: B
Rationale: The correct answer is B: Elevated blood pressure. Pheochromocytoma is a tumor of the adrenal gland that secretes excessive catecholamines, leading to hypertension. The excess release of epinephrine and norepinephrine causes vasoconstriction, resulting in increased blood pressure. This is a hallmark sign of pheochromocytoma.
A: Decreased pulse is not typically associated with pheochromocytoma due to the stimulatory effect of catecholamines on the heart.
C: Cold intolerance is not a common manifestation of pheochromocytoma and is more indicative of thyroid dysfunction.
D: Decreased respiratory rate is not a common finding in pheochromocytoma, as it does not directly affect respiratory function.
Question 5 of 5
A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?
Correct Answer: C
Rationale: The correct answer is C: Gather further assessment data. This is appropriate because calf pain during walking could indicate a potential serious condition like deep vein thrombosis (DVT) in pregnancy. Gathering further assessment data will help the nurse determine the underlying cause of the calf pain and provide appropriate interventions. Instructing the client to limit walking episodes (
A) may not address the root cause, telling the client it's normal (
B) may overlook a serious issue, and instructing to elevate legs (
D) may not be the most appropriate action without a thorough assessment.