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Ati capstone exam
Ati capstone exam
Total Questions : 51
Showing 10 questions Sign up for moreA nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
Explanation
Choice A rationale
Eating a high fiber diet will reduce my risk for developing skin cancer. This statement is incorrect because a high fiber diet has not been proven to reduce the risk of developing skin cancer. Skin cancer is primarily caused by exposure to ultraviolet (UV) radiation from the sun or artificial sources like tanning booths.
Choice B rationale
I should check my skin monthly for any changes. This statement is correct. Regular self- examinations can help detect skin cancer early when it is most treatable. The American Academy of Dermatology recommends checking your skin from head to toe every month.
Choice C rationale
I should avoid the use of tanning booths. This statement is correct. Tanning booths emit UV radiation, which increases the risk of developing skin cancer. Avoiding tanning booths is a crucial preventive measure.
Choice D rationale
I should use sunscreen even on cloudy days. This statement is correct. UV rays can penetrate clouds, so it is essential to use sunscreen every day, regardless of the weather, to protect the skin from harmful UV radiation.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
Explanation
Choice A rationale
Avoid handwashing after eating. This statement is incorrect. Handwashing is a critical preventive measure to reduce the risk of viral hepatitis, especially after eating or using the restroom.
Choice B rationale
Avoid foods prepared with tap water. This statement is correct. In areas where the water supply may be contaminated, it is essential to avoid foods prepared with tap water to reduce the risk of viral hepatitis, particularly hepatitis A, which can be transmitted through contaminated food and water.
Choice C rationale
Avoid eating meat. This statement is incorrect. While it is essential to ensure that meat is cooked thoroughly to prevent foodborne illnesses, avoiding meat altogether is not a specific preventive measure for viral hepatitis.
Choice D rationale
Avoid covering sores with bandages. This statement is incorrect. Covering sores with bandages can help prevent the spread of infections, including viral hepatitis, by reducing the risk of contact with infectious fluids.
A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)
Explanation
Choice A rationale
Palpate the area behind the ankle bone. This action is correct. The posterior tibial pulse is located behind the medial malleolus (ankle bone), and palpating this area is necessary to assess the pulse.
Choice B rationale
Use the pads of the fingers to feel for the pulse. This action is correct. Using the pads of the fingers provides a more sensitive and accurate assessment of the pulse compared to using the fingertips or thumb.
Choice C rationale
Compare the pulse strength with the other leg. This action is correct. Comparing the pulse strength bilaterally helps identify any discrepancies that may indicate vascular issues.
Choice D rationale
Assess for any swelling or tenderness. This action is incorrect. While assessing for swelling or tenderness is essential in a general physical examination, it is not a specific step in assessing the posterior tibial pulse.
The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate.
The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
Explanation
Choice A rationale
Fever usually accompanies myocardial infarction. This statement is incorrect. While fever can occur with myocardial infarction, it is not a common or primary symptom. Acetaminophen is not prescribed for this reason.
Choice B rationale
Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does. This statement is correct but not the reason for prescribing acetaminophen before nitrates. Acetaminophen is chosen for its analgesic properties without affecting platelet function.
Choice C rationale
Headache is a common side effect of nitrates. This statement is correct. Nitrates can cause vasodilation, leading to headaches. Acetaminophen is prescribed to manage this common side effect.
Choice D rationale
Acetaminophen potentiates the therapeutic effect of nitrates. This statement is incorrect. Acetaminophen does not enhance the therapeutic effects of nitrates; it is used to manage side effects like headaches.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation.
Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
Explanation
Choice A rationale
Irregular pulse. While an irregular pulse is a common finding in atrial fibrillation, it is not the most critical finding to report immediately unless it is associated with other symptoms.
Choice B rationale
Persistent fatigue. Persistent fatigue is a common symptom in heart failure and atrial fibrillation but does not require immediate reporting unless it worsens significantly.
Choice C rationale
Dependent edema. Dependent edema is a common symptom in heart failure but does not require immediate reporting unless it is severe or worsening rapidly.
Choice D rationale
Slurred speech. This finding is critical to report immediately as it may indicate a stroke or transient ischemic attack (TIA) due to an embolus from atrial fibrillation. Prompt intervention is necessary to prevent further complications. .
A nurse is assessing a client who has cirrhosis.
Which of the following is an expected finding for this client?
Explanation
Choice A rationale
Moist skin is not typically associated with cirrhosis. Cirrhosis often leads to dry, itchy skin due to bile salt accumulation under the skin.
Choice B rationale
Blood in the urine is not a common finding in cirrhosis. This symptom is more indicative of urinary tract issues or kidney problems.
Choice C rationale
Spider angiomas are a common finding in clients with cirrhosis. These are small, dilated blood vessels that appear close to the surface of the skin and are caused by increased estrogen levels due to liver dysfunction.
Choice D rationale
Tarry stools indicate gastrointestinal bleeding, which can occur in cirrhosis due to varices, but it is not a primary expected finding.
A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
Explanation
Choice A rationale
A daily caloric intake of 25% fat is within the recommended range and does not significantly increase the risk for peripheral arterial disease (PAD).
Choice B rationale
Diabetes mellitus is a significant risk factor for PAD. High blood sugar levels can damage blood vessels and lead to poor circulation.
Choice C rationale
Consuming two 12-ounce alcoholic beverages daily can contribute to other health issues but is not a primary risk factor for PAD.
Choice D rationale
Hypothyroidism is not directly linked to an increased risk of PAD. It can cause other cardiovascular issues but not specifically PAD.
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?
Explanation
Choice A rationale
Weak pedal pulses indicate vascular compromise, which is a complication of Buck’s traction. This can be caused by pressure on the tissues of the leg.
Choice B rationale
Complaints of leg discomfort are expected due to the traction and do not indicate a complication.
Choice C rationale
Toes that are warm and demonstrate brisk capillary refill are normal findings and do not indicate a complication.
Choice D rationale
Drainage at the pin sites is more relevant to skeletal traction, not Buck’s traction.
When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?
Explanation
Choice A rationale
Flank pain with radiation to the groin and hematuria are more indicative of kidney issues, not heart failure.
Choice B rationale
Respiratory distress, chest pain, and use of accessory muscles can indicate respiratory issues but are not specific to heart failure.
Choice C rationale
Crackles, peripheral edema, and weight gain are classic signs of heart failure. These symptoms indicate fluid overload and poor cardiac function.
Choice D rationale
Confusion, decreasing level of consciousness, and aphasia are neurological symptoms and not specific to heart failure.
A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea.
The nurse should suspect that the client has developed which of the following complications?
Explanation
Choice A rationale
Airway obstruction is not a common complication of a femoral head fracture or skin traction.
Choice B rationale
Pneumonia can cause shortness of breath but is not the most likely complication in this scenario.
Choice C rationale
Pneumothorax is less likely in this context compared to a fat embolism.
Choice D rationale
Fat embolism is a known complication of fractures, especially long bone fractures like the femoral head. It can cause respiratory distress and dyspnea.
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