ATI RN
ATI Capstone Exam 1 Questions
Extract:
Question 1 of 5
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)
Correct Answer: 100
Rationale: The correct answer is 100 gtt/min.
To calculate the IV flow rate in gtt/min for microtubing, you can use the formula: gtt/min = (mL/hr x tubing factor) / 60. In this case, the mL/hr is 100, and for microtubing, the tubing factor is usually 60. So, (100 x 60) / 60 = 100 gtt/min. This ensures the dextrose 5% in 0.45% sodium chloride solution is infused at the correct rate. Other choices would be incorrect because they do not follow the correct calculation for microtubing flow rates.
Question 2 of 5
A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Log roll the client every 2 hours. This action is crucial for preventing complications such as pressure ulcers and maintaining spinal alignment post spinal fusion surgery. Log rolling helps to keep the spine in proper alignment and reduces the risk of injury to the surgical site. Assisting the client to sit upright for 4 hours at a time (choice
A) can put excessive pressure on the surgical site and hinder the healing process. Expecting clear drainage on the spinal dressing (choice
B) is not appropriate as drainage may vary and is not necessarily an indicator of infection. Performing neurological checks every 8 hours (choice
D) is important but should be done more frequently in the immediate postoperative period.
Question 3 of 5
A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Increase your daily intake of dietary fiber. Verapamil, a calcium channel blocker used for angina, can cause constipation as a side effect. Increasing dietary fiber helps prevent constipation by promoting bowel regularity. This instruction is important for the client's overall well-being and medication compliance.
A: Swelling of the ankles is not a common side effect of verapamil.
B: Verapamil can be taken with or without food, so taking it on an empty stomach is not necessary.
C: There is no need to limit fluid intake to meal times while taking verapamil.
Question 4 of 5
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?
Correct Answer: A
Rationale: The correct initial action is to check the drainage for glucose (
Choice
A). This is crucial because clear drainage after a transsphenoidal hypophysectomy may indicate a cerebrospinal fluid leak, which can be confirmed by the presence of glucose in the drainage. If glucose is present, it suggests leakage of cerebrospinal fluid and requires immediate intervention to prevent complications such as infection and meningitis. The other options (B, C, and
D) are not the most appropriate initial actions. Notifying the provider, documenting the amount of drainage, or obtaining a culture can be important steps but should come after confirming the presence of glucose to address the immediate concern of a potential cerebrospinal fluid leak.
Question 5 of 5
A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
Correct Answer: D
Rationale: The correct answer is D: a client who has a lumbosacral spinal tumor. This client may require meal assistance due to potential physical limitations caused by the tumor. The nurse should delegate this task to the AP because it falls within their scope of practice.
Choice A (Guillain-Barré syndrome),
Choice B (systemic sclerosis), and
Choice C (ALS) all involve neuromuscular conditions that can affect the client's ability to swallow or chew, and thus meal assistance should be provided by a higher-level healthcare provider.
In summary, the correct answer is D because the client with a lumbosacral spinal tumor is more likely to need assistance with meals due to physical limitations, and the AP is appropriate for this task. The other choices involve conditions where meal assistance may require more specialized care.