ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for mechanical ventilation. In a myasthenic crisis, respiratory muscles become severely weakened, leading to respiratory failure. Mechanical ventilation is crucial to support breathing and oxygenation. Administering sedatives (choice
A) can further depress respiratory function. Instructing pursed lip breathing (choice
B) may not be sufficient in severe cases. Administering a vasoconstrictor (choice
D) is not indicated in myasthenic crisis.
Question 2 of 5
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Correct Answer: C
Rationale: The correct answer is C: Increase in the heart rate from 88 to 110/min. This finding indicates the client may be developing hypovolemic shock because an increase in heart rate is a classic compensatory mechanism in response to decreased blood volume, which is characteristic of hypovolemic shock. The body tries to maintain cardiac output by increasing heart rate to ensure adequate tissue perfusion.
Other choices are incorrect because:
A: Increase in temperature is more indicative of an inflammatory response, not necessarily hypovolemic shock.
B: Decrease in respiratory rate is not a typical sign of hypovolemic shock.
D: Decrease in urinary output is a sign of decreased renal perfusion but not specific to hypovolemic shock.
Question 3 of 5
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5.3
Rationale:
To calculate the correct dose, we first convert the child's weight from lb to kg: 28 lb / 2.2 = 12.73 kg.
Then, we multiply the weight by the dose (10 mg/kg): 12.73 kg * 10 mg/kg = 127.3 mg. Next, we convert mg to mL using the available concentration: 127.3 mg / 120 mg = 1.06 mL, which rounds to 1 decimal place as 5.3 mL.
Therefore, the nurse should administer 5.3 mL. Other choices are incorrect because they do not follow the correct conversion and calculation steps, leading to inaccurate dosing.
Question 4 of 5
What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: The correct signs and symptoms for meningitis include fever and chills due to systemic infection, nuchal rigidity from meningeal irritation, severe headache from increased intracranial pressure, and Brudzinski's sign, which indicates meningeal irritation when the neck is flexed. Bradycardia is not a typical sign of meningitis. The summary of why the other choices are incorrect is that they do not align with the classic signs and symptoms of meningitis, which are mainly related to systemic infection and meningeal irritation.
Question 5 of 5
A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Measure the client's apical pulse. This is crucial before administering digoxin because it helps monitor the client's heart rate, as digoxin can cause bradycardia or dysrhythmias. Monitoring the apical pulse ensures the heart rate is within the safe range for administering the medication.
The other choices are incorrect because:
B: Measuring the client's blood pressure is not specifically necessary before administering digoxin, as the primary concern is monitoring the heart rate.
C: Offering the client a light snack is irrelevant to the administration of digoxin and does not impact the medication's effectiveness or safety.
D: Weighing the client is not directly related to administering digoxin and does not provide information necessary for ensuring safe administration.