ATI RN
ATI Capstone Exam 2 Final Questions
Extract:
Question 1 of 5
A nurse is triaging victims of a multiple motor vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse of 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Place a black tag on the client's upper body and attempt to help the next client in need. In a multiple casualty incident, the concept of triage is crucial to prioritize care. The client in this scenario is apneic despite repositioning the airway, indicating a poor prognosis. Placing a black tag signifies that the client is not breathing and has no pulse, and resources should be allocated to those with a higher chance of survival. This decision maximizes the overall number of lives saved.
Choice A is incorrect because further repositioning will not change the client's status.
Choice B is incorrect as placing a red tag is reserved for clients with immediate life-threatening injuries but still have a chance of survival.
Choice D would be inappropriate as CPR is not indicated when the client does not have a pulse.
Question 2 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 3 of 5
A nurse is preparing to administer amoxicillin 500 mg PO four times a day to a client. The amount available is amoxicillin suspension 250 mg/5 mL. How many mL should the nurse administer per dose?
Correct Answer: 10
Rationale: The correct answer is 10 mL.
To calculate this, we first find the total daily dose of amoxicillin (500 mg x 4 doses = 2000 mg).
Then, we convert this to mL using the concentration of the suspension (250 mg/5 mL). 2000 mg ÷ 250 mg/mL = 8 mL per dose. Since the question asks for the total mL per dose, we multiply 8 mL by 1.25 (to account for 500 mg instead of 400 mg), giving us 10 mL. Other choices are incorrect because they do not follow the correct conversion process or do not consider the total daily dose of amoxicillin needed.
Question 4 of 5
A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child’s cooperation?
Correct Answer: A
Rationale: The correct answer is A. Offering the child a choice of taking the medication with juice or water empowers the child and gives them a sense of control over the situation, increasing the likelihood of cooperation. This strategy respects the child's autonomy and preferences, fostering a positive relationship between the child and the nurse. It also promotes trust and reduces anxiety associated with taking medication.
Other choices are incorrect because:
B: Lying to the child by telling them the medication is candy is unethical and can lead to trust issues.
C: Threatening the child with a shot instills fear and is coercive, which can lead to negative associations with taking medication.
D: Hiding the medication in ice cream may lead to the child developing mistrust towards food and medication, and it does not address the underlying issue of the child's resistance.
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.