ATI RN
ATI Capstone Week 9 Exam Questions
Extract:
Question 1 of 5
A nurse is reviewing a client's laboratory results and sees that their hemoglobin A1C is 9%. Which of the following statements from the nurse is appropriate?
Correct Answer: C
Rationale:
Rationale:
Choice C is correct because Hemoglobin A1C reflects average blood sugar levels over the past 2-3 months. A level of 9% indicates high average blood sugar.
Choice A is incorrect because A1C does not specifically indicate post-meal blood sugar.
Choice B is incorrect as A1C doesn't measure low blood sugar levels.
Choice D is incorrect as A1C reflects overall blood sugar control, not stability.
Question 2 of 5
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client's respiratory status. Slow, steady bubbling in the suction control chamber indicates that the system is functioning properly. This bubbling is expected as it shows that the system is maintaining the desired negative pressure. Monitoring the client's respiratory status is essential to ensure that there are no underlying respiratory complications post-thoracotomy.
Option B is incorrect because clamping the chest tube can lead to a tension pneumothorax. Option C is incorrect as checking the suction control outlet on the wall is not necessary in this situation. Option D is incorrect as checking tubing connections for leaks is not indicated when there is slow, steady bubbling. It's crucial to understand the rationale behind each option to make the best clinical decision.
Extract:
Nurses' Notes
Day 1:
1000:
Client alert and oriented x3. Lung fields clear, heart rhythm regular bowel sounds normoactive x4; ate 75% of morning meal. Denies pain. Left forearm arteriovenous (AV) fistula, skin warm, brachial and radial pulses 2+
1600:
Client returned from dialysis, lethargic, not hungry, tried to eat a few crackers but vomited them up. Capillary blood glucose 134 mg/dL. AV fistula site skin warm, bruit and thrill noted, brachial and radial pulses palpable.
Day 2:
0700:
Client reports not sleeping well last night; capillary blood glucose 75 mg/dL; crackles in left lower lobe: unproductive cough: AV fistula site ecchymotic, warm, bruit and thrill noted. Oriented to person, place, and time.
A nurse is caring for a client receiving hemodialysis.
Vital Signs
Nurses' NotesVital SignsMedical History
Day 1:
1000:
Temperature 36.3°C (97.3°F)
Heart rate 70/min
Respiratory rate 16/min
Blood pressure 144/72 mm Hg
Oxygen saturation 94% on room air
Weight 90 kg (198 lb)
1600:
Temperature 37.1 °C (98.7°F)
Heart rate 62/min
Respiratory rate 16/min
Blood pressure 112/54 mm Hg
Oxygen saturation 95% on room air
Day 2:
0700:
Temperature 36.7°C (98.1°F)
Heart rate 62/min
Respiratory rate 12/min
Blood pressure 118/52 mmHg
Oxygen saturation 95% on room air
Weight 86.4 kg (190)
A nurse is caring for a client receiving hemodialysis.
Medical History
Nurses' NotesVital SignsMedical History
Client has a history of type 2 diabetes mellitus, and hemodialysis with Arteriovenous fistula.
A nurse is caring for a client receiving hemodialysis.
Question 3 of 5
A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up?
Correct Answer: B,E,F
Rationale: The correct answer is B, E, and F. Weight monitoring is crucial in patients receiving hemodialysis due to fluid shifts. Changes in lung sounds can indicate fluid overload or pulmonary edema. Assessing the AV fistula site is important to ensure patency and prevent infection. Vital signs are typically monitored during hemodialysis sessions and should be stable. Blood glucose levels are not directly impacted by hemodialysis. Presence of bruit and thrill at the fistula site is a normal finding indicating good blood flow.
Extract:
Question 4 of 5
A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?
Correct Answer: D
Rationale:
Correct Answer: D - "I must avoid blowing my nose and bending at the waist."
Rationale: After a transsphenoidal hypophysectomy, it is crucial to avoid blowing the nose and bending at the waist to prevent increased intracranial pressure and potential leakage of cerebrospinal fluid through the surgical site. This instruction helps to protect the surgical area and prevent complications such as meningitis. By following this advice, the client demonstrates an understanding of the importance of protecting the surgical site and minimizing risks of postoperative complications.
Summary of Incorrect
Choices:
A: Restricting fluid intake is not necessary after a transsphenoidal hypophysectomy.
B: Deep breathing exercises are typically encouraged to prevent respiratory complications postoperatively.
C: Lying flat for an extended period after surgery can increase the risk of complications such as venous thromboembolism.
Question 5 of 5
A nurse is teaching a client who has diabetes mellitus and a new prescription for glimepiride. The nurse should teach the client to avoid which of the following drinks while taking this medication?
Correct Answer: C
Rationale: The correct answer is C: Alcohol. Glimepiride, a sulfonylurea medication, can cause a disulfiram-like reaction when consumed with alcohol, leading to symptoms like nausea, vomiting, flushing, and rapid heart rate. Coffee (
A) and milk (
B) do not have interactions with glimepiride. Grapefruit juice (
D) can interact with certain medications but not with glimepiride. In summary, alcohol should be avoided due to the potential for a harmful reaction when taken with glimepiride.