ATI RN
ATI Capstone Exam 1 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 at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: In a mass casualty event, a client who remains apneic after airway repositioning is unlikely to survive and should receive a black tag, indicating resources should be allocated to others with better survival chances. Further repositioning, CPR, or a red tag are inappropriate due to limited resources and low survival likelihood.
Question 2 of 5
A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Checking aPTT every 6 hours ensures heparin dosing is therapeutic, preventing clotting or bleeding complications. High-dose boluses are unsafe, vitamin K is for warfarin, and no special tubing is needed for heparin, making these incorrect.
Question 3 of 5
A nurse is caring for a client who is postpartum and asks the nurse when her breast milk will 'come in.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: Most women transition from colostrum to mature milk 3 to 5 days postpartum, often experiencing engorgement as production increases. Earlier (2 days) is less common, and later (6–10 days) may indicate delayed lactation requiring medical evaluation.
Question 4 of 5
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Examining breasts in the shower with soapy hands facilitates detecting lumps, as soap allows smoother gliding. Using the palm is incorrect (finger pads are used), dimpling/discharge requires medical evaluation, and BSE should be done post-menstruation when breasts are less tender.
Question 5 of 5
A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
Correct Answer: D
Rationale: A client with a lumbosacral spinal tumor is least likely to have swallowing issues, making meal assistance appropriate for the AP. Guillain-Barré, systemic sclerosis, and ALS can impair swallowing, requiring specialized nurse-led feeding to prevent aspiration.