ATI RN
ATI Capstone Week 9 Exam Questions
Extract:
Question 1 of 5
A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Urine output is less than 400 mL per 24 hr. During the oliguric phase of acute kidney injury, there is a significant decrease in urine output, usually less than 400 mL per 24 hours. This occurs due to a decrease in glomerular filtration rate and impaired kidney function. BUN and creatinine levels actually increase during this phase due to impaired kidney function, so option A is incorrect. The GFR does not recover during the oliguric phase, so option C is incorrect. Renal function is not reestablished during the oliguric phase; it may improve in the diuretic phase that follows, making option D incorrect.
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.
Question 3 of 5
A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)
Correct Answer: A,B,C,E
Rationale: The correct manifestations to monitor for in a client with acute respiratory failure (ARF) are decreased level of consciousness (
A), hypercarbia (
B), severe dyspnea (
C), and tachycardia (E). 1) Decreased level of consciousness indicates poor oxygenation to the brain due to inadequate gas exchange. 2) Hypercarbia, an increased level of carbon dioxide in the blood, is a common finding in ARF as the lungs fail to adequately remove CO2. 3) Severe dyspnea is a hallmark sign of ARF, indicating the body's struggle to obtain adequate oxygen. 4) Tachycardia is the body's compensatory response to hypoxia and respiratory distress.
Choices D, F, and G are incorrect because nausea is not a typical manifestation of ARF, and options F and G are not provided.
Question 4 of 5
A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching? (Select all that apply.)
Correct Answer: A,C,D,E
Rationale: The correct answers are A, C, D, and E.
A: Reducing cholesterol and saturated fat intake helps in managing blood lipid levels and reduces the risk of cardiovascular complications often associated with diabetes.
C: Maintaining optimal blood pressure is crucial to prevent kidney damage, as high blood pressure can worsen kidney function in diabetic patients.
D: Increasing physical activity and daily exercise helps in managing blood glucose levels, improving insulin sensitivity, and reducing the risk of cardiovascular complications.
E: Enrolling in a smoking cessation program is important because smoking increases the risk of cardiovascular disease and other complications in individuals with diabetes.
Incorrect choices:
B: Sustaining hyperglycemia is incorrect as it can lead to nerve damage and other complications in diabetes management.
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 5 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.