ATI RN
ATI Capstone Week 9 Exam Questions
Extract:
Question 1 of 5
A nurse is preparing a client for a kidney biopsy. Which of the following client conditions should the nurse identify as a contraindication for this diagnostic test?
Correct Answer: C
Rationale: The correct answer is C: Coagulation disorder. A kidney biopsy involves inserting a needle into the kidney to obtain a tissue sample. If a client has a coagulation disorder, there is an increased risk of excessive bleeding during the procedure. This could lead to serious complications such as hemorrhage.
Flank pain (
A) is a common symptom in kidney conditions but is not a contraindication for a kidney biopsy. Elevated creatinine level (
B) may indicate kidney dysfunction but is not a direct contraindication for the procedure. Urinary retention (
D) does not directly affect the safety of a kidney biopsy.
Question 2 of 5
A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?
Correct Answer: C
Rationale: The correct action for the nurse to take first is to perform a bladder scan (
Choice
C). This is the most appropriate initial step to assess the client's bladder volume without being invasive. It allows the nurse to determine if the client is retaining urine, which could be causing the inability to void. If the bladder scan shows a large volume of urine, then the nurse can proceed with appropriate interventions such as catheterization. Providing assistance to the bathroom (
Choice
A) may not be effective if there is significant urinary retention. Increasing fluids (
Choice
B) may worsen the situation by further distending the bladder. Inserting a straight catheter (
Choice
D) without assessing the bladder volume can be harmful and should only be done after determining the need through a bladder scan.
Question 3 of 5
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: Keeping the drainage system below the level of the client's chest prevents the backflow of air or fluid into the client's chest, ensuring proper functioning of the chest tube. This positioning maintains the integrity of the closed drainage system and prevents complications such as pneumothorax or hemothorax.
Summary of other choices:
B: Clamping the chest tube can lead to a buildup of pressure in the chest, causing potential harm to the client.
C: Disconnecting the chest tube can result in air entering the pleural space, increasing the risk of pneumothorax.
D: Emptying the collection chamber is not necessary prior to transport as it does not affect the function of the chest tube.
Question 4 of 5
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Correct Answer: D
Rationale:
Rationale: The correct answer is D. Encouraging the client to drink 2 to 3 L of water daily is essential in helping with tenacious bronchial secretions in COPD. Adequate hydration thins mucus, making it easier to expectorate. Options A, B, and C do not directly address the issue of thinning secretions. Administering oxygen helps with oxygenation, low-salt diet is for managing hypertension, and semi-Fowler's position aids with breathing but doesn't directly address secretions.
Question 5 of 5
A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?
Correct Answer: D
Rationale:
Correct Answer: D - "I must avoid blowing my nose and bending at the waist."
Rationale: After a transsphenoidal hypophysectomy, it is crucial to avoid blowing the nose and bending at the waist to prevent increased intracranial pressure and potential leakage of cerebrospinal fluid through the surgical site. This instruction helps to protect the surgical area and prevent complications such as meningitis. By following this advice, the client demonstrates an understanding of the importance of protecting the surgical site and minimizing risks of postoperative complications.
Summary of Incorrect
Choices:
A: Restricting fluid intake is not necessary after a transsphenoidal hypophysectomy.
B: Deep breathing exercises are typically encouraged to prevent respiratory complications postoperatively.
C: Lying flat for an extended period after surgery can increase the risk of complications such as venous thromboembolism.