ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
Correct Answer: D
Rationale:
Rationale: The correct answer is D. DIC is caused by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the clotting cascade, leading to the formation of microthrombi throughout the body. This consumption of clotting factors, including fibrinogen, results in bleeding tendencies. Lifelong heparin usage (
A) is not a treatment for DIC. DIC is characterized by low platelet count, not elevated (
B). DIC is an acquired condition, not a genetic disorder (
C) involving vitamin K deficiency.
Question 2 of 5
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: Hypovolemia. A low CVP in a client with multiple traumas indicates decreased blood volume, leading to hypovolemia. This can be due to blood loss from trauma. Other choices are incorrect: A (Fluid overload) would result in elevated CVP, C (Left ventricular failure) would typically show an elevated CVP, and D (Intracardiac shunt) would not directly affect CVP. It is crucial for the nurse to recognize hypovolemia promptly in trauma patients to initiate appropriate interventions.
Question 3 of 5
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Excessive thrombosis and bleeding. In DIC, there is widespread activation of the coagulation cascade leading to the formation of microthrombi in small blood vessels, causing tissue ischemia and organ dysfunction. This results in excessive clot formation (thrombosis) in some areas and simultaneous consumption of clotting factors and platelets, leading to bleeding in other areas. The other choices are incorrect because:
A) In DIC, there is consumption of clotting factors, leading to a decrease rather than an increase.
C) Platelet production may be increased initially to compensate for consumption, but it is not a progressive increase.
D) Sodium and fluid retention are not typical findings in DIC.
Question 4 of 5
A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?
Correct Answer: D
Rationale: The correct answer is D: Dorsiflexion of the great toe. Babinski's sign is an abnormal response where the great toe extends and the other toes fan out when the sole of the foot is stroked. In this scenario, a client with an unrepaired femur fracture suddenly becoming stuporous may indicate increased intracranial pressure. Assessing for Babinski's sign helps in detecting neurological abnormalities.
Choices A, B, and C are unrelated to Babinski's sign and are not indicative of neurological issues. Jerking contractions of the head and neck, pinpoint pupils, and pronation of the arms are not specific to Babinski's sign and do not provide relevant information in this situation.
Question 5 of 5
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
Correct Answer: C
Rationale:
Correct Answer: C. Pacemaker spikes before each QRS complex.
Rationale: In a client with a ventricular pacemaker, the pacemaker spike should precede the QRS complex since the pacemaker is responsible for initiating the electrical impulse to stimulate ventricular depolarization. This is known as ventricular pacing. The presence of the pacemaker spike before each QRS complex indicates proper functioning of the pacemaker and effective capture of the ventricles. This ensures that the heart is being paced appropriately, maintaining the heart rate and rhythm.
Summary:
A: Pacemaker spikes with each T wave - Incorrect. Pacemaker spikes should precede QRS complex, not T wave.
B: Pacemaker spikes before each P wave - Incorrect. Ventricular pacemakers are responsible for pacing the ventricles, not atria.
D: Pacemaker spikes after each QRS complex - Incorrect. Pacemaker spikes should precede QRS complex for effective pacing.