ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 of 5
A nurse is preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate. Magnesium sulfate is a medication that can cause respiratory depression. Monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress or depression promptly. This assessment is a priority because respiratory depression can lead to serious complications, including respiratory arrest. Assessing bowel sounds (choice
A), temperature (choice
C), and fetal heart rate (choice
D) are important but not as critical as monitoring the respiratory rate when administering magnesium sulfate. Bowel sounds may indicate gastrointestinal motility issues, temperature changes may indicate infection, and fetal heart rate is important in pregnancy but not the priority when administering magnesium sulfate.
Question 2 of 5
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Terbutaline is a beta-adrenergic agonist that can cause pulmonary edema as a serious adverse effect. Dyspnea is a common symptom of pulmonary edema, indicating potential respiratory distress. This adverse effect should be reported promptly to the provider for further evaluation and management to prevent complications.
Incorrect choices:
B: Headaches - Headaches are a common side effect of terbutaline but are not as concerning as respiratory distress.
C: Nervousness - Nervousness is a common side effect of terbutaline and does not typically require immediate reporting unless severe.
D: Tremors - Tremors are a common side effect of terbutaline and are not as concerning as respiratory distress.
Question 3 of 5
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client’s vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 97.6°F. Which of the following is the priority nursing action?
Correct Answer: B
Rationale: The correct answer is B: Initiate IV access. The priority nursing action in this scenario is to ensure IV access to administer necessary medications or fluids in case of an emergency. The client's vital signs indicate hypotension and tachycardia, which could be signs of hypovolemic shock due to significant bleeding. Initiating IV access promptly can help stabilize the client's condition and prevent further complications.
Choice A is incorrect because obtaining informed consent for surgery is not the immediate priority in this situation.
Choice C is incorrect as inserting a urinary catheter is not urgent compared to addressing the potential hypovolemia.
Choice D is incorrect as preparing the abdominal and perineal areas is not as urgent as addressing the client's hemodynamic instability.
Question 4 of 5
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? Select all that apply:
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A: Antibiotic ointment to both eyes is given to prevent neonatal conjunctivitis. B: Hepatitis B immunization is crucial for newborns to prevent Hepatitis B infection. E: Vitamin K injection is given to prevent hemorrhagic disease of the newborn. C: Lidocaine gel to the umbilical stump is not a standard practice and can cause local irritation. D: Haemophilus influenzae type b immunization is typically given later in infancy, not immediately after birth.
Question 5 of 5
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. This muscle is the preferred site for IM injections in infants due to its large muscle mass and minimal risk of injury to nerves and blood vessels. The dorsogluteal site (choice
A) is not recommended for neonates due to the risk of damaging the sciatic nerve. The deltoid muscle (choice
C) is not suitable for newborns as it lacks adequate muscle mass and can lead to nerve injury. The ventrogluteal site (choice
D) can be used in older infants but is not the preferred site for newborns.