ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse who is mentoring a graduate nurse explains the correlation between severe blood loss and the effect on the client's mean arterial pressure (MAP). The graduate nurse demonstrates correct understanding when he states which of the following:
Correct Answer: D
Rationale: The correct answer is D: Lower blood volume lowers MAP. Mean Arterial Pressure (MAP) is determined by cardiac output and systemic vascular resistance. Severe blood loss results in decreased blood volume, leading to a decrease in cardiac output. With lower cardiac output, there is less blood being pumped into the arteries, resulting in lower pressure exerted on the arterial walls, hence lowering the MAP.
Choices A and B are incorrect as severe blood loss reduces cardiac output and would not raise it or cause vasoconstriction.
Choice C is incorrect as there is a direct correlation between blood loss and MAP.
Extract:
Medical History
0900:
Client had a left-hemisphere stroke with right-sided arm mild expressive aphasia. Client is able to ambulate with assistance. Client is alert to person and place but is unable to tell the date and time.
Nurses' Notes
1000:
Client is assisted out of bed to chair. Client is sitting upright eating breakfast. Bilateral breath sounds clear and present throughout. Client drools and clears throat when eating. Voice hoarse after swallowing.
1800:
Client coughing frequently. Breath sounds with crackles heard in right upper lobe.
Vital Signs
1000:
Temperature 37.2° C (99° F) Blood pressure 128/76 mm Hg Heart rate 86/min Respirations 18/min
Oxygen saturation 96% on room air
1800:
Temperature 39.6° C (103.3° F) Blood Pressure 118/78 mm Hg Heart Rate 104/min Respiration rate 24/min
Oxygenation saturation 92% on room air
Question 2 of 5
A nurse is caring for a client who has had a stroke. Select the 3 findings that require immediate follow-up.
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Drooling (
A) could indicate difficulty swallowing or airway compromise. A hoarse voice (
D) may suggest vocal cord dysfunction, which could lead to airway obstruction. Elevated temperature (E) could indicate infection, especially concerning in stroke patients. Blood pressure at 180 (
B) is high but not immediately life-threatening. Breath sounds at 1000 (
C) and missing options (F, G) are not directly related to immediate follow-up in this scenario.
Extract:
Question 3 of 5
The emergency department nurse is preparing an infusion of IV alteplase for a client who suffered a cerebrovascular accident (CVA). Which of the following statements is accurate about the administration of alteplase?
Correct Answer: B
Rationale: The correct answer is B. Alteplase is administered as a bolus over 1-2 minutes, followed by a continuous infusion over 60 minutes. This rapid administration is crucial for the drug's thrombolytic action to dissolve the clot causing the CVA. Giving it as a bolus over 3 minutes (option
B) is not accurate, as it should be given over a shorter time frame. Option A is incorrect because alteplase can be given to patients on anticoagulant or antiplatelet therapy with caution. Option C is incorrect as the recommended time for administration is within 3 hours of symptom onset, not 90 minutes after admission. Option D is incorrect as the maximum dosage of alteplase is 0.9 mg/kg, not a fixed 120 mg dose.
Question 4 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Elevate the head of the bed. This intervention helps to promote venous drainage from the head, reducing intracranial pressure. Elevating the head of the bed also helps to improve cerebral blood flow.
Choices B, C, and D are incorrect. A brightly lit environment can increase stimulation and exacerbate symptoms. Encouraging a high intake of fluids can lead to fluid overload and worsen intracranial pressure. Teaching controlled coughing and deep breathing does not directly address the increased intracranial pressure concern.
Question 5 of 5
A nurse who is mentoring a graduate nurse explains the correlation between severe blood loss and the effect on the client's mean arterial pressure (MAP). The graduate nurse demonstrates correct understanding when he states which of the following:
Correct Answer: D
Rationale: The correct answer is D: Lower blood volume lowers MAP. Mean Arterial Pressure (MAP) is determined by cardiac output and systemic vascular resistance. Severe blood loss results in decreased blood volume, leading to a decrease in cardiac output. With lower cardiac output, there is less blood being pumped into the arteries, resulting in lower pressure exerted on the arterial walls, hence lowering the MAP.
Choices A and B are incorrect as severe blood loss reduces cardiac output and would not raise it or cause vasoconstriction.
Choice C is incorrect as there is a direct correlation between blood loss and MAP.