ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is providing teaching about dietary recommendations to a client who has iron deficiency anemia. Which of the following dietary recommendations should the nurse include as a food that enhances iron absorption when consumed with nonheme iron?
Correct Answer: D
Rationale: The correct answer is D:
Tomato juice.
Tomato juice contains vitamin C, which enhances the absorption of nonheme iron. Vitamin C helps to convert nonheme iron into a more absorbable form, increasing the body's ability to take in iron from plant-based sources. Tea (
A) contains compounds that can inhibit iron absorption. Dried beans (
B) contain phytates that can reduce iron absorption. Milk (
C) contains calcium which can inhibit iron absorption.
Therefore, the best recommendation for enhancing iron absorption when consuming nonheme iron is to include foods rich in vitamin C, such as tomato juice.
Question 2 of 5
A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction?
Correct Answer: C
Rationale: The correct answer is C: Urticaria. Urticaria, also known as hives, is a common manifestation of an allergic reaction. It presents as raised, itchy welts on the skin. This is a classic symptom of an allergic response to medication like oxacillin. Dark urine (
A) is more indicative of liver issues, diarrhea (
B) can be a side effect of many medications, and fever (
D) can be a sign of infection rather than an allergic reaction.
Question 3 of 5
A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate?
Correct Answer: A
Rationale: The correct answer is A: 90 bpm. For infants, a normal heart rate is typically around 120-160 bpm. However, the threshold for administering digoxin is usually set at a lower rate to prevent toxicity. If the infant's heart rate is below 90 bpm, it may indicate bradycardia, which is a contraindication for digoxin administration as it can further slow down the heart rate and lead to serious complications.
Therefore, withholding the dose is crucial to prevent harm to the infant.
Choices B, C, and D are incorrect as they are higher heart rates and would not be the threshold for withholding the dose.
Question 4 of 5
A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?
Correct Answer: A
Rationale: The correct answer is A: pH 7.26, HCO₃ 14, PaCO₂ 30. In acute kidney injury (AKI), the kidneys cannot regulate acid-base balance, leading to metabolic acidosis. The pH is low (acidosis), HCO₃ is low indicating metabolic acidosis, and PaCO₂ is low due to compensatory respiratory alkalosis.
Choices B and D have high pH values, which are not consistent with metabolic acidosis.
Choice C has a normal HCO₃ value, which is not expected in AKI.
Choice C also has a high PaCO₂, which is not consistent with compensatory respiratory alkalosis in metabolic acidosis.
Question 5 of 5
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Test the drainage for glucose. This is the first action the nurse should take because clear drainage from the nose following a basal skull fracture may indicate a cerebrospinal fluid (CSF) leak. Testing the drainage for glucose can help differentiate between CSF and other types of nasal discharge. If the drainage tests positive for glucose, it confirms the presence of CSF. This finding is crucial for determining the appropriate management and potential complications associated with a CSF leak.
Summary of other choices:
A: Asking the client to blow his nose is not appropriate as it can increase intracranial pressure.
B: Suctioning the nostril can worsen the CSF leak and should be avoided.
C: Notifying the physician is important, but testing the drainage for glucose should be done first.
E, F, G: No additional options provided, but none would be more appropriate than testing the drainage for glucose.