ATI RN
ATI Capstone Exam Questions
Extract:
Question 1 of 5
The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
Correct Answer: A
Rationale: The correct answer is A: Weak pedal pulses. Buck's traction is used for immobilization and alignment of fractures, particularly femoral fractures. Weak pedal pulses indicate impaired circulation, which could lead to complications like compartment syndrome or deep vein thrombosis. Monitoring pulses is crucial in assessing the circulation to the affected limb.
Choice B (Complaints of leg discomfort) is common and expected with traction but doesn't indicate a complication.
Choice C (
Toes are warm and demonstrate a brisk capillary refill) indicates good circulation.
Choice D (Drainage at the pin sites) may indicate infection but is not a specific complication related to traction.
Question 2 of 5
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for an elevated temperature. This is important because an elevated temperature could indicate infection, which is a significant concern when a client has a halo fixation device. Removing the vest daily (
Choice
A) is not recommended as it can compromise the stability of the device. Checking that the halo jacket is snug (
Choice
B) is important, but monitoring for an elevated temperature is a higher priority. Providing range of motion to the client's neck (
Choice
C) is contraindicated with a halo device as it can cause serious injury.
Question 3 of 5
A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
Correct Answer: B
Rationale: The correct answer is B: Use a new cosmetic pad with each limited application of makeup. This is important to prevent the spread of bacteria and reduce the risk of exacerbating acne. Using a new pad each time helps to avoid introducing more bacteria to the skin.
Choice A is incorrect because friction can irritate the skin and worsen acne.
Choice C is incorrect as oil-based soap can clog pores and worsen acne.
Choice D is incorrect because expressing comedones can lead to scarring and infection. It's crucial to provide accurate and evidence-based information to clients to promote effective management of their condition.
Question 4 of 5
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)
Correct Answer: B,C
Rationale: The correct answers are B: Hypotension and C: Poor skin turgor. In a client with frequent vomiting and diarrhea, fluid loss leads to dehydration, causing hypotension and poor skin turgor. Hypotension results from decreased circulating blood volume due to fluid loss. Poor skin turgor occurs due to decreased skin elasticity from dehydration.
Choices A, D, and E are incorrect. Fat neck veins are not typical findings in dehydration. Bradycardia is not expected in dehydration; tachycardia is more common due to compensatory mechanisms to maintain cardiac output. Pale yellow urine is indicative of concentrated urine, not a typical finding in dehydration.
Question 5 of 5
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the burn injury. What percentage of body surface area should the nurse estimate?
Correct Answer: D
Rationale: The nurse should estimate the percentage of body surface area affected by the burn injury using the Rule of Nines. According to this rule, specific body areas are assigned percentages: head (9%), each arm (9% total), each leg (18% total), front torso (18%), back torso (18%), and perineum (1%). By adding these percentages, a total of 100% is obtained. For severe burns, the nurse should estimate using the Rule of Nines, making D (8%) the most appropriate choice as it closely aligns with the total percentage of body surface area affected by the burn.
Choices A, B, C, and E do not align with the Rule of Nines and would not accurately estimate the extent of the burn injury.