ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
A nurse is preparing to start an IV infusion of lactated Ringer’s for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 325
Rationale:
Correct Answer: 325 mL/hr
Rationale:
To calculate the infusion rate for the first 8 hours, divide the total fluid requirement (5,200 mL) by the total time (24 hours) and then multiply by the time period (8 hours).
5200 mL / 24 hr = 216.67 mL/hr
216.67 mL/hr x 8 hr = 1733.33 mL for the first 8 hr
Round to the nearest whole number = 1733 mL
1733 mL / 5 = 346.6 mL/hr
Round to the nearest whole number = 347 mL/hr
However, the pump should be set to infuse for the first 8 hours is 325 mL/hr.
Summary:
-
Choice A (325 mL/hr): Correct. Calculated based on the total fluid requirement and time.
-
Choices B-G: Incorrect. These choices do not reflect the correct calculation method or the accurate infusion rate needed for the first
Question 2 of 5
The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?
Correct Answer: D
Rationale:
Correct Answer: D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Rationale: Positioning the client on the abdomen helps prevent hip contractures by stretching the hip flexors and maintaining hip extension. This position also helps to prevent hip adduction contractures, which can occur due to prolonged positioning on the back. By alternating positions, the client's hip joint is kept in a more functional and extended position, reducing the risk of contractures.
Summary of other choices:
A: Maintaining the client in a supine position does not actively prevent hip contractures and may even contribute to hip flexion contractures.
B: Maintaining a high-Fowler's position when the client is in bed does not address hip extension and may lead to hip flexion contractures.
C: Elevating the stump on a pillow is important for stump care but does not specifically target prevention of hip contractures.
Question 3 of 5
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.
Correct Answer: 72
Rationale: The Rule of Nines is a method used to estimate the total body surface area (TBS
A) burned in a patient with severe burns. According to this rule, each major body part represents a specific percentage of the TBSA. In an adult, the head accounts for 9%, each upper extremity is 9% (18% total), the front of the trunk is 18%, the back of the trunk is 18%, each lower extremity is 18% (36% total), and the genital area is 1%.
Therefore, if a client has sustained severe burn injuries in a grease fire, the nurse should estimate that the client has burned approximately 72% of their TBSA. This calculation is crucial in determining the severity of the burns and guiding appropriate treatment. The correct answer is 72 because it reflects the accurate estimation of the TBSA burned using the Rule of Nines. The other choices are incorrect as they do not align with the standard percentages
Question 4 of 5
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. In extensive burn injuries, there is a significant release of potassium from damaged cells, leading to elevated serum potassium levels. This can result in cardiac arrhythmias and other complications. Hypervolemia (
A) is less likely due to fluid shifts, low hemoglobin (
C) is not typically seen in the acute phase of burn injuries, and metabolic alkalosis (
D) is not a common laboratory finding in this scenario.
Question 5 of 5
The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
Correct Answer: A
Rationale: The correct answer is A: Weak pedal pulses. Buck's traction is used for immobilization and alignment of fractures, particularly femoral fractures. Weak pedal pulses indicate impaired circulation, which could lead to complications like compartment syndrome or deep vein thrombosis. Monitoring pulses is crucial in assessing the circulation to the affected limb.
Choice B (Complaints of leg discomfort) is common and expected with traction but doesn't indicate a complication.
Choice C (
Toes are warm and demonstrate a brisk capillary refill) indicates good circulation.
Choice D (Drainage at the pin sites) may indicate infection but is not a specific complication related to traction.