ATI RN
ATI Capstone Week 9 Exam Questions
Extract:
Question 1 of 5
What information would the nurse include when educating a postsurgical client on the proper use of antiembolism stockings? (Select all that apply)
Correct Answer: A,C,D,E
Rationale: A: Correct. Educating the client on the impairment to blood flow if the stockings are too tight is crucial to prevent complications like impaired circulation or pressure ulcers.
C: Correct. Ensuring skin hygiene and assessment each time the stockings are removed helps in early detection of any skin issues or irritations.
D: Correct. Wearing the stockings both in and out of bed promotes continuous prevention of blood clots, especially during periods of immobility.
E: Correct. Measuring the length and circumference of the leg ensures proper fit, which is essential for the stockings to be effective.
Incorrect choices: B is incorrect as the stockings should be worn continuously, not removed daily for 30 minutes.
Question 2 of 5
A nurse is teaching a client who has diabetes mellitus and a new prescription for glimepiride. The nurse should teach the client to avoid which of the following drinks while taking this medication?
Correct Answer: C
Rationale: The correct answer is C: Alcohol. Glimepiride, a sulfonylurea medication, can cause a disulfiram-like reaction when consumed with alcohol, leading to symptoms like nausea, vomiting, flushing, and rapid heart rate. Coffee (
A) and milk (
B) do not have interactions with glimepiride. Grapefruit juice (
D) can interact with certain medications but not with glimepiride. In summary, alcohol should be avoided due to the potential for a harmful reaction when taken with glimepiride.
Question 3 of 5
A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?
Correct Answer: 4
Rationale: The correct answer is 4 mL.
To calculate this, we use the formula: Desired dose/Available dose = Volume to administer. In this case, 40 mg/10 mg/mL = 4 mL. Each mL contains 10 mg of furosemide, so to administer 40 mg, the nurse should give 4 mL. Other choices are incorrect because they do not follow the correct calculation. For example, choosing 10 mL (choice G) would result in administering 100 mg, not the desired 40 mg.
Question 4 of 5
A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?
Correct Answer: D
Rationale:
Correct Answer: D - "I must avoid blowing my nose and bending at the waist."
Rationale: After a transsphenoidal hypophysectomy, it is crucial to avoid blowing the nose and bending at the waist to prevent increased intracranial pressure and potential leakage of cerebrospinal fluid through the surgical site. This instruction helps to protect the surgical area and prevent complications such as meningitis. By following this advice, the client demonstrates an understanding of the importance of protecting the surgical site and minimizing risks of postoperative complications.
Summary of Incorrect
Choices:
A: Restricting fluid intake is not necessary after a transsphenoidal hypophysectomy.
B: Deep breathing exercises are typically encouraged to prevent respiratory complications postoperatively.
C: Lying flat for an extended period after surgery can increase the risk of complications such as venous thromboembolism.
Question 5 of 5
A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?
Correct Answer: C
Rationale: The correct action for the nurse to take first is to perform a bladder scan (
Choice
C). This is the most appropriate initial step to assess the client's bladder volume without being invasive. It allows the nurse to determine if the client is retaining urine, which could be causing the inability to void. If the bladder scan shows a large volume of urine, then the nurse can proceed with appropriate interventions such as catheterization. Providing assistance to the bathroom (
Choice
A) may not be effective if there is significant urinary retention. Increasing fluids (
Choice
B) may worsen the situation by further distending the bladder. Inserting a straight catheter (
Choice
D) without assessing the bladder volume can be harmful and should only be done after determining the need through a bladder scan.