ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is preparing to administer clindamycin by intermittent IV bolus over 30 minutes to a client who has a staphylococcal infection. Available is 300 mg clindamycin premixed in 50 mL 0.9% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr?
Correct Answer: 100
Rationale: The correct answer is 100 mL/hr.
To calculate the rate, we first determine the total volume to be infused over 30 minutes (50 mL).
Then, we convert 30 minutes to hours (0.5 hours). Finally, we divide the total volume by the time in hours (50 mL / 0.5 hr = 100 mL/hr). This rate ensures the clindamycin is administered safely and effectively. Other choices are incorrect because they do not align with the calculated infusion rate based on the medication concentration and administration time.
Question 2 of 5
A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?
Correct Answer: A
Rationale: The correct answer is A. Vitamin K is essential for bone health as it helps in calcium absorption and bone mineralization.
Therefore, reducing intake of vitamin K-rich foods can be detrimental in preventing osteoporosis.
Choices B, C, and D are all correct as they are beneficial in preventing osteoporosis by reducing sodium, caffeine, and soft drink intake, respectively. These choices help in maintaining bone density and overall bone health.
Question 3 of 5
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Restrict head movement. This instruction is crucial to prevent any further detachment of the retina before surgery. Excessive head movements can exacerbate the condition. Removing the eye patch in one month (
B) is incorrect as it does not address pre-operative care. Applying cool compresses (
C) may not be appropriate as it could interfere with the surgical site. Prescribing eye drops to constrict pupils (
D) is not necessary before surgery for retinal detachment.
Question 4 of 5
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
Correct Answer: A
Rationale: The correct answer is A: Adopt a neutral attitude when providing care. This approach is appropriate because it allows the nurse to establish trust and build rapport with the suspicious client without overwhelming them. Being neutral helps to convey non-judgmental and non-threatening behavior, which is essential in gaining the client's trust. Waiting for the client to initiate interaction (
B) may lead to prolonged periods of mistrust. Disclosing personal information (
C) can blur professional boundaries and may further increase the client's suspicion. Approaching the client frequently (
D) may be perceived as invasive and could escalate the client's distrust.
Therefore, adopting a neutral attitude is the most suitable approach in this situation.
Question 5 of 5
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale:
Correct Answer: C
Rationale:
1. Enoxaparin is an anticoagulant administered subcutaneously.
2. The air bubble in the prefilled syringe acts as a safety feature to prevent leakage of the medication.
3. Expelling the air bubble can lead to loss of medication, affecting dosage accuracy.
4.
Therefore, the nurse should not expel the air bubble to ensure the client receives the correct dose.
Summary:
A: Aspirating for a blood return is not necessary for subcutaneous injections.
B: Inserting the needle at a 45-degree angle is not specific to enoxaparin administration.
D: Administering 2.54 cm from the umbilicus is not a standard guideline for enoxaparin injections.