ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?
Correct Answer: B
Rationale: The correct answer is B. The nurse should be concerned because squinting to see the board may indicate vision problems, such as nearsightedness or astigmatism, which can affect the child's learning and development. The other choices are not as concerning: A is a common behavior in children, C is a normal developmental milestone, and D is a typical behavior in board games at this age.
Question 2 of 5
A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention?
Correct Answer: C
Rationale: Tertiary prevention aims to reduce the impact of established disease through treatment and rehabilitation. Performing screening for sexually transmitted infections falls under tertiary prevention as it helps identify and manage existing infections, preventing complications and further transmission.
Incorrect choices:
A: Testing new nurses for exposure to tuberculosis is an example of secondary prevention, aimed at early detection and treatment to prevent the progression of disease.
B: Providing treatment for clients with chronic obstructive pulmonary disease is an example of secondary prevention, focusing on managing existing conditions to prevent complications.
D: Administering influenza immunizations at a local health fair is an example of primary prevention, aiming to prevent the initial occurrence of illness through vaccination.
Question 3 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.
Question 4 of 5
A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?
Correct Answer: B
Rationale: The correct answer is B: Reposition the client at least every 2 hours. Repositioning helps to relieve pressure on the ulcer, promoting healing and preventing further damage. This intervention is crucial in managing pressure ulcers. Applying a heat lamp (choice
A) can worsen the ulcer by increasing the risk of tissue damage. Massaging reddened areas with dressing changes (choice
C) can also cause further damage to the fragile skin. Cleaning the wound with hydrogen peroxide (choice
D) can be too harsh and delay the healing process.
Therefore, choice B is the most appropriate intervention for a client with a stage 3 pressure ulcer.
Question 5 of 5
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B: Perform a neurovascular assessment. This is the priority action because it ensures circulation and nerve function are intact, preventing complications like compartment syndrome. Explanation of discharge instructions (
A) is important but not the priority. Providing reassurance (
C) is supportive but not urgent. Applying an ice pack (
D) can cause skin damage due to decreased sensation.