ATI RN
ATI Capstone Week 9 Exam Questions
Extract:
Question 1 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 2 of 5
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because administering insulin injections in the abdominal area helps with faster absorption and consistent insulin action. This practice is recommended for clients with type 1 diabetes to maintain stable blood sugar levels.
Choice B is incorrect as blood sugar readings should ideally be taken before meals.
Choice C is incorrect because insulin does not allow unrestricted consumption of high-sugar foods like ice cream.
Choice D is incorrect because a weight reduction program, if managed properly, should not lead to hypoglycemia in a client with type 1 diabetes.
Question 3 of 5
A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?
Correct Answer: C
Rationale: The correct action for the nurse to take first is to perform a bladder scan (
Choice
C). This is the most appropriate initial step to assess the client's bladder volume without being invasive. It allows the nurse to determine if the client is retaining urine, which could be causing the inability to void. If the bladder scan shows a large volume of urine, then the nurse can proceed with appropriate interventions such as catheterization. Providing assistance to the bathroom (
Choice
A) may not be effective if there is significant urinary retention. Increasing fluids (
Choice
B) may worsen the situation by further distending the bladder. Inserting a straight catheter (
Choice
D) without assessing the bladder volume can be harmful and should only be done after determining the need through a bladder scan.
Question 4 of 5
A nurse is assessing a client who has thyrotoxicosis after taking too high of a level of levothyroxine. Which of the following manifestations should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Heat intolerance. Thyrotoxicosis, caused by excessive levothyroxine intake, results in excessive thyroid hormone levels leading to increased metabolism. This increased metabolism causes the body to produce excess heat, resulting in heat intolerance. Drowsiness (
A) is not a typical manifestation of thyrotoxicosis; instead, patients may experience insomnia or restlessness due to hyperactivity. Bradycardia (
C) is a manifestation of hypothyroidism, the opposite condition of thyrotoxicosis. Dry skin (
D) is also a manifestation of hypothyroidism due to decreased metabolic activity.
Question 5 of 5
A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?
Correct Answer: C
Rationale: The correct answer is C: Gentamicin. Gentamicin is an aminoglycoside antibiotic known to cause nephrotoxicity, particularly in patients with chronic kidney disease due to its potential to accumulate in the kidneys. This can lead to kidney damage and impaired renal function. Ondansetron (
A) and Diphenhydramine (
B) are not typically associated with nephrotoxicity. Omeprazole (
D) is a proton pump inhibitor used for acid-related disorders and is not known to cause nephrotoxicity.