ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Place a red tag on the client's upper body. This is the correct action because in mass casualty incidents, triage tags are used to prioritize care. A red tag indicates the client has life-threatening injuries requiring immediate attention. Performing a rapid head-to-toe assessment (choice
A) would delay urgent treatment. Having the client's wife drive him to the hospital (choice
C) is not appropriate as the client needs immediate medical attention. Placing a yellow tag (choice
D) would indicate delayed treatment, which is not suitable for an open fracture.
Question 2 of 5
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?
Correct Answer: A
Rationale: The correct answer is A: Fetal position is persistent occiput posterior. This position is associated with prolonged labor and severe backache due to the baby's head pressing against the mother's sacrum. A gynecoid pelvis (
B) is actually favorable for labor, not a contributing cause. Fetal attitude in general flexion (
C) is also favorable for labor. Fetal lie being longitudinal (
D) is normal.
Question 3 of 5
A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate 8/min. Morphine sulfate is an opioid that can cause respiratory depression as an adverse effect. A respiratory rate of 8/min is significantly below the normal range (12-20/min) and indicates respiratory depression, a serious adverse effect of morphine. This finding requires immediate intervention to prevent further complications such as respiratory arrest.
Choice A (Sleepy, but arousing when her name is called) is a common side effect of morphine but not necessarily an adverse effect requiring immediate intervention.
Choice C (Pain level of 6 on a scale from 0 to 10) is not indicative of an adverse effect of morphine.
The other choices are not provided, but they would be incorrect as they do not indicate a serious adverse effect of morphine sulfate.
Question 4 of 5
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Correct Answer: A
Rationale: The correct answer is A: Muffled heart sounds. In cardiac tamponade, fluid accumulates in the pericardial sac, compressing the heart. This results in muffled heart sounds due to decreased sound transmission through the fluid. Sudden lethargy (
B) may indicate worsening condition but is not specific to cardiac tamponade. Flattened neck veins (
C) are typically seen in hypovolemic shock, not cardiac tamponade. Bradycardia (
D) is not a common finding in cardiac tamponade, as it usually presents with tachycardia due to the heart's compensatory mechanisms.
Question 5 of 5
A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A. Using handrails in the bathroom promotes safety by providing support and stability, reducing the risk of falls. This indicates an understanding of fall prevention.
Choice B about a longer telephone cord is unrelated to fall prevention.
Choice C increases the risk of tripping over cords.
Choice D suggests using chairs without armrests can affect stability and increase the risk of falls.