ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse’s priority?
Correct Answer: D
Rationale: The correct answer is D: Blood pressure 80/56 mm Hg. This finding is the priority because it indicates hypotension, a common side effect of opioid epidural analgesia. Hypotension can lead to decreased placental perfusion and compromise fetal well-being. The other options are less urgent: A slight fever (
A) is common with epidural analgesia, weakness of lower extremities (
B) is an expected side effect, and itching (
C) is a common minor side effect.
Therefore, monitoring and addressing the client's low blood pressure is the priority to prevent potential harm to both the mother and the baby.
Question 3 of 5
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
Correct Answer: D
Rationale: The correct answer is D because the situation involves a potential harm to a client, which is a critical incident requiring documentation. The missing dentures can impact the client's ability to eat or speak, posing a risk to their well-being. Completing an incident report ensures the issue is addressed, investigated, and preventive measures are implemented to avoid future occurrences.
Choices A, B, and C do not directly involve harm to a client and can be addressed through other means without the need for an incident report.
Question 4 of 5
A nurse is planning on teaching a client who is scheduled for an IVP. Which of the following statements should the nurse include in the teaching?
Correct Answer: D
Rationale: The correct answer is D: After the procedure, you will be encouraged to drink plenty of fluids. This is important because after an Intravenous Pyelogram (IVP), the contrast dye used can be nephrotoxic, and increasing fluid intake helps to flush out the dye and prevent kidney damage. Encouraging the client to drink plenty of fluids will help protect their kidneys.
Choice A is incorrect because the presence of red blood cells in the urinalysis is not a contraindication for an IVP.
Choice B is incorrect because the client may need to follow specific dietary restrictions before and after the test.
Choice C is incorrect because high-frequency sound waves are used in ultrasound, not in an IVP.
Question 5 of 5
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (G85). Which of the following questions should the nurse ask the client?
Correct Answer: A
Rationale: The nurse should ask about recent influenza infection (
Choice
A) because Guillain-Barré syndrome is often preceded by a viral illness, such as influenza. This information is crucial for diagnosis and treatment. Travel history (
Choice
B) is less relevant as the cause is more likely viral. Chronic alcohol abuse (
Choice
C) and multivitamin use (
Choice
D) are not directly related to Guillain-Barré syndrome.