ATI RN
ATI Capstone Week 10 Exam Questions
Extract:
Question 1 of 5
Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back. The nurse contacts the primary health care provider and begins to document on an incident report. Which information should be included?
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the key information related to the client's condition after receiving meperidine. Documenting the time of temperature elevation and the actual temperature is crucial for monitoring the client's response to the medication. This information helps in assessing for potential adverse reactions or side effects of meperidine.
Choice A is incorrect because attributing the reaction solely to an allergic response without concrete evidence is premature.
Choice B is incorrect as it focuses on the notification of the primary health care provider rather than the essential clinical data.
Choice C is incorrect as it mentions the physical findings but lacks the critical data of the temperature elevation. The other choices (E, F, G) are not relevant to the situation described.
In summary, documenting the specific temperature change after medication administration is essential for assessing the client's response and guiding further interventions.
Question 2 of 5
A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?
Correct Answer: C
Rationale: The correct answer is C: Notify the surgeon. When purulent drainage is observed postoperatively following a corneal transplant, it indicates a potential infection. The nurse's priority is to notify the surgeon immediately to address the infection promptly to prevent further complications. Applying a non-pressure patch (choice
A) or cleaning the eye (choice
B) may not address the underlying infection. Instilling an antibiotic solution (choice
D) without consulting the surgeon may not be appropriate as the surgeon may need to assess the situation first.
Question 3 of 5
A nurse in an oncology unit is assessing a client who has early-stage Hodgkin’s lymphoma. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Enlarged lymph nodes. In early-stage Hodgkin's lymphoma, enlarged lymph nodes are a common finding due to the abnormal growth of lymphocytes. This occurs as the cancer affects the lymphatic system. The presence of painless, firm, and rubbery lymph nodes that are fixed in place is a key characteristic. The nurse should assess for these enlarged lymph nodes in various areas of the body, such as the neck, armpits, or groin. A productive cough (
A) is not typically associated with early-stage Hodgkin's lymphoma. Bone and joint pain (
B) are more commonly seen in conditions like arthritis, not specifically in early-stage Hodgkin's lymphoma. Intermittent hematuria (
C) is not a typical finding in Hodgkin's lymphoma, as it is more indicative of urinary tract problems rather than lymphoma involvement.
Question 4 of 5
A nurse is providing discharge instructions for a client following surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Restrict lifting objects greater than 10 pounds. After intraocular lens surgery, the client should avoid lifting heavy objects to prevent increased intraocular pressure which can lead to complications. Option A is incorrect because vision should improve, not reduce, after the procedure. Option C is incorrect as aspirin can increase the risk of bleeding post-surgery. Option D is incorrect as warm compresses can increase inflammation and discomfort.
Question 5 of 5
A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Speak directly to the client in a normal, clear voice. This is the most appropriate action as it ensures effective communication without being patronizing or disrespectful. Speaking directly and clearly helps the client understand the information being conveyed. Speaking loudly (
A) may distort sound and not necessarily improve comprehension. Using sign language (
B) assumes the client knows sign language, which may not be the case. Speaking slowly (
C) can be perceived as condescending and may not necessarily improve understanding.