Ati capstone week 10 exam
Total Questions : 43
Showing 25 questions, Sign in for moreA 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?
Explanation
Choice A rationale
Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.
Choice B rationale
Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.
Choice C rationale
Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.
Choice D rationale
Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client’s provider?
Explanation
Choice A rationale
Itching is a common symptom after cataract surgery, and the client should be reminded not to rub or place pressure on the eyes. This comment does not indicate a serious complication.
Choice B rationale
Sensitivity to bright light is also common after cataract surgery. The client can be advised to wear sunglasses to reduce discomfort. This comment does not indicate a serious complication.
Choice C rationale
Fear of falling is a valid concern, especially if the client has impaired vision or depth perception due to the eye patch. However, this comment does not indicate a serious complication that needs immediate reporting.
Choice D rationale
Severe pain in the eye after cataract surgery can indicate a complication such as increased intraocular pressure, infection, or hemorrhage. This comment should be reported to the provider immediately for further evaluation and intervention.
A nurse is instructing the caregiver of a child who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide?
Explanation
Choice A rationale
Applying the ointment in a thin line into the conjunctival sac ensures that the medication is properly distributed across the surface of the eye, allowing for effective treatment of the bacterial conjunctivitis.
Choice B rationale
Asking the child to look down before applying the ointment is not necessary and may make the application process more difficult. The focus should be on ensuring the ointment is applied correctly.
Choice C rationale
Using a sterile glove and applicator is not required for applying ophthalmic ointment. Clean hands and proper technique are sufficient to ensure safe and effective application.
Choice D rationale
Wiping from the outer to the inner canthus is incorrect. The correct technique is to wipe from the inner to the outer canthus to prevent the spread of infection.
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following instructions should the nurse include?
Explanation
Choice A rationale
Applying cool compresses can help reduce swelling and discomfort, but it is not the primary instruction for a client scheduled for retinal detachment surgery.
Choice B rationale
Eye drops to constrict the pupils are not typically prescribed for retinal detachment surgery. The focus is on preventing further detachment and ensuring proper healing.
Choice C rationale
Restricting head movement is crucial to prevent further detachment of the retina and to promote proper healing after surgery. The client should be instructed to avoid sudden or excessive head movements.
Choice D rationale
Keeping both eyes patched is not necessary and may cause unnecessary discomfort and disorientation for the client.
A client receiving infliximab through intravenous infusion is reporting difficulty swallowing. Which immediate action would the nurse take?
Explanation
Choice A rationale
Shutting off the intravenous infusion is the immediate action to take when a client reports difficulty swallowing during infliximab infusion. This could indicate an infusion reaction or anaphylaxis, which requires immediate cessation of the infusion to prevent further complications.
Choice B rationale
Notifying the primary health care provider is important, but the immediate action should be to stop the infusion to prevent further adverse reactions.
Choice C rationale
Having the client take deep breaths and try to relax is not appropriate in this situation, as it does not address the potential infusion reaction or anaphylaxis.
Choice D rationale
Obtaining a prescription for oral diphenhydramine may be part of the treatment for an infusion reaction, but the immediate action should be to stop the infusion. .
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report:
Explanation
Choice A rationale
Cataracts cause the lens of the eye to become cloudy, leading to a decreased ability to perceive colors. This is due to the scattering of light as it passes through the cloudy lens, which reduces the clarity and vibrancy of colors.
Choice B rationale
Loss of peripheral vision is more commonly associated with glaucoma, a condition where increased intraocular pressure damages the optic nerve.
Choice C rationale
Seeing bright flashes of light and floaters is typically a symptom of retinal detachment, a serious condition where the retina pulls away from its normal position.
Choice D rationale
Loss of central vision is often linked to macular degeneration, a condition that affects the central part of the retina responsible for sharp, detailed vision.
While working in the emergency department, the unit secretary says, “We just got a call that someone with a severe peanut allergy accidentally ate peanuts and is on the way.”. Which emergency equipment would the nurse gather to prepare for the client’s arrival? Select all that apply.
Explanation
Choice A rationale
Intubation equipment and oxygen are essential for managing airway obstruction and ensuring adequate oxygenation in a patient experiencing anaphylaxis due to a severe peanut allergy.
Choice B rationale
Epinephrine is the first-line treatment for anaphylaxis as it rapidly reverses the symptoms by constricting blood vessels, relaxing muscles in the airways, and reducing swelling.
Choice C rationale
Blood administration equipment is not typically required for managing anaphylaxis unless there is a concurrent condition that necessitates it.
Choice D rationale
A Foley catheter is not relevant to the immediate management of anaphylaxis.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse’s priority?
Explanation
Choice A rationale
A CD4-T-cell count of 180 cells/mm³ indicates severe immunosuppression in a client with HIV, making them highly susceptible to opportunistic infections. This is a critical value that requires immediate attention to prevent life-threatening complications.
Choice B rationale
A positive Western blot test confirms the presence of HIV antibodies but does not indicate the current immune status or the urgency of the client’s condition.
Choice C rationale
Platelets at 150,000/mm³ are within the normal range and do not indicate an immediate threat to the client’s health.
Choice D rationale
A WBC count of 5,000/mm³ is within the normal range and does not indicate an immediate threat to the client’s health.
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?
Explanation
Choice A rationale
The Visual Analog Scale is used for older children and adults who can understand and communicate their pain level.
Choice B rationale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed for assessing pain in infants and young children who are unable to communicate their pain verbally.
Choice C rationale
The Oucher scale is used for children aged 3 to 12 years and involves matching facial expressions to a pain level.
Choice D rationale
The Faces scale is used for children aged 3 years and older who can point to a face that best represents their pain level.
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client’s chest. The lesion is raised and flesh-colored with pearly and waxy borders that are well defined. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?
Explanation
Choice A rationale
Actinic keratosis is a precancerous condition that appears as rough, scaly patches on sun-exposed skin.
Choice B rationale
Malignant melanoma is a more aggressive form of skin cancer that often appears as a new, unusual growth or a change in an existing mole.
Choice C rationale
Squamous cell carcinoma typically appears as a firm, red nodule or a flat lesion with a scaly, crusted surface.
Choice D rationale
Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly and waxy borders. It is the most common type of skin cancer and typically occurs in areas exposed to the sun.
Which instructions would the nurse provide to the client about the prevention and early detection of Lyme disease? Select all that apply.
Explanation
Choice A rationale
Avoiding the use of insect repellent on the skin and clothing is not recommended. Insect repellents containing DEET are effective in preventing tick bites, which can transmit Lyme disease. The toxicity of DEET is minimal when used as directed.
Choice B rationale
Avoiding heavily wooded areas and areas with thick underbrush is recommended to reduce the risk of tick exposure. Ticks that carry Lyme disease are commonly found in these environments.
Choice C rationale
Wearing dark clothing is not recommended as it makes it harder to spot ticks. Light-colored clothing is preferable as it allows for easier detection of ticks.
Choice D rationale
Wearing long-sleeved tops and long pants with closed shoes is recommended to minimize skin exposure and reduce the risk of tick bites.
Choice E rationale
Reporting to the primary health care provider immediately for a blood test if a tick is found is not necessary. The presence of a tick does not immediately indicate Lyme disease. Instead, the tick should be removed promptly, and the area should be monitored for signs of infection.
Choice F rationale
Bathing after being in an infested area and inspecting the body carefully for ticks is recommended. This helps in early detection and removal of ticks, reducing the risk of Lyme disease.
A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take?
Explanation
Choice A rationale
Speaking loudly and into the client’s good ear is not recommended. Loud speech can be distorted and uncomfortable for individuals with presbycusis.
Choice B rationale
Using sign language is not necessary unless the client is proficient in it. Most clients with presbycusis benefit more from clear verbal communication.
Choice C rationale
Sitting by the client’s side and speaking very slowly is not as effective as speaking directly to the client in a normal, clear voice.
Choice D rationale
Speaking directly to the client in a normal, clear voice is recommended. This ensures that the client can read lips and understand the conversation better.
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
Explanation
Choice A rationale
Administering an IM injection does not typically require a gown as personal protective equipment unless there is a risk of exposure to blood or body fluids.
Choice B rationale
Completing a dressing change requires a gown to protect against potential exposure to blood or body fluids.
Choice C rationale
Administering an intermittent IV bolus medication does not typically require a gown unless there is a risk of exposure to blood or body fluids.
Choice D rationale
Talking to the client at the bedside does not require a gown as there is no risk of exposure to blood or body fluids.
The nurse is collecting data to determine the client’s risk factors related to cervical cancer. The nurse determines which information to be significant?
Explanation
Choice A rationale
Multiple sexual partners increase the risk of human papillomavirus (HPV) infection, which is a significant risk factor for cervical cancer.
Choice B rationale
Multiple pregnancies are not a significant risk factor for cervical cancer.
Choice C rationale
Late onset of menarche is not a significant risk factor for cervical cancer.
Choice D rationale
Use of a diaphragm is not a significant risk factor for cervical cancer.
A client diagnosed with bowel cancer has recently received a course of chemotherapy and has now developed stomatitis. The nurse provides instructions to the client regarding the condition and determines the need for further teaching if the client makes which statement?
Explanation
Choice A rationale
Drinking room temperature beverages can help minimize irritation in the mouth and throat, which is beneficial for clients with stomatitis. Cold or hot beverages can exacerbate the condition by causing discomfort and pain.
Choice B rationale
Taking a prescribed analgesic can help manage the pain associated with stomatitis. Pain management is crucial for maintaining the client’s comfort and ability to eat and drink.
Choice C rationale
Stomatitis is not contagious and cannot be spread to family members. This statement indicates a need for further teaching as it reflects a misunderstanding of the condition.
Choice D rationale
Chemotherapy can affect the immune system, making the client more susceptible to infections and conditions like stomatitis. This statement is accurate and does not indicate a need for further teaching.
A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
Explanation
Choice A rationale
Pitting edema of the hands and fingers is not a typical finding in clients with systemic lupus erythematosus (SLE). Edema can occur in SLE, but it is more commonly associated with renal involvement and not specifically pitting edema of the hands and fingers.
Choice B rationale
Subcutaneous nodules on the ulnar side of the arm are more commonly associated with rheumatoid arthritis rather than SLE. SLE does not typically present with subcutaneous nodules.
Choice C rationale
A dry, red rash across the bridge of the nose and on the cheeks, known as a “butterfly rash,” is a classic sign of SLE. This rash is caused by inflammation of the small blood vessels in the skin and is often exacerbated by sun exposure.
Choice D rationale
A grey-colored, non-purpuric papular rash is not characteristic of SLE. The typical rash in SLE is the butterfly rash, which is dry, red, and raised.
A nurse is providing care to a child who has an allergy to eggs. The nurse should clarify a prescription for which of the following immunizations?
Explanation
Choice A rationale
Inactivated poliovirus (IPV) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice B rationale
Hepatitis B (HepB) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice C rationale
Haemophilus influenzae type b (Hib) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice D rationale
Influenza, live attenuated (LAIV) vaccine contains egg protein and can cause severe allergic reactions in individuals with egg allergies. This prescription should be clarified to ensure the safety of the child.
A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?
Explanation
Choice A rationale
A phlebotomist who collects blood from clients who have HIV is at the greatest risk for contracting HIV. This is because they are frequently exposed to blood, which is a bodily fluid that can transmit HIV if proper precautions are not taken.
Choice B rationale
A nurse who works for an insurance company and collects urine samples from clients who have HIV is at a lower risk compared to a phlebotomist. Urine is not a common transmission route for HIV.
Choice C rationale
An occupational therapist who works with a client who has HIV is at a lower risk compared to a phlebotomist. Occupational therapists are not typically exposed to blood or other high-risk bodily fluids.
Choice D rationale
A personal trainer who works with a client who has HIV is at a lower risk compared to a phlebotomist. Personal trainers are not typically exposed to blood or other high-risk bodily fluids.
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?
Explanation
Choice A rationale
A productive cough is not a typical finding in early-stage Hodgkin’s lymphoma. Respiratory symptoms are more commonly associated with other conditions.
Choice B rationale
Bone and joint pain are not typical findings in early-stage Hodgkin’s lymphoma. These symptoms are more commonly associated with other conditions such as metastatic cancer or rheumatoid arthritis.
Choice C rationale
Intermittent hematuria is not a typical finding in early-stage Hodgkin’s lymphoma. Hematuria is more commonly associated with urinary tract infections or kidney conditions.
Choice D rationale
Enlarged lymph nodes are a common finding in early-stage Hodgkin’s lymphoma. This condition is characterized by the presence of Reed-Sternberg cells in the lymph nodes, leading to their enlargement.
A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
Explanation
Choice A rationale
Administering the medications 5 minutes apart ensures that each medication has enough time to be absorbed without interference from the other. This practice helps to maximize the effectiveness of both medications and reduces the risk of adverse interactions.
Choice B rationale
Touching the tip of the dropper to the sclera of the eye can introduce contaminants and increase the risk of infection. It is important to avoid contact between the dropper and the eye to maintain sterility.
Choice C rationale
Holding pressure on the conjunctival sac for 2 minutes is not necessary for the administration of timolol and pilocarpine eye drops. This practice is more commonly recommended for other types of eye medications to increase absorption.
Choice D rationale
Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. Wearing contact lenses during administration can interfere with the effectiveness of the drops.
A community health nurse is preparing a poster for an educational session for a group of women with whom she will be discussing the risk factors for breast cancer. Which factors increase the risk for breast cancer and should be listed on the poster? Select all that apply.
Explanation
Choice A rationale
A family history of breast cancer is a significant risk factor because genetic mutations, such as BRCA1 and BRCA2, can be inherited and increase the likelihood of developing breast cancer.
Choice B rationale
Multiparity (having multiple pregnancies) is generally considered to reduce the risk of breast cancer. This is because pregnancy and breastfeeding lower the number of menstrual cycles a woman has, reducing her lifetime exposure to estrogen.
Choice C rationale
Exposure of the chest to high-dose radiation, especially during childhood or young adulthood, increases the risk of breast cancer. Radiation can cause mutations in breast cells, leading to cancer.
Choice D rationale
Previous cancer of the breast, uterus, or ovaries increases the risk of developing breast cancer. This is due to shared risk factors and the possibility of metastasis or recurrence.
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?
Explanation
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
The nurse is creating a plan of care for a client diagnosed with Sjögren’s syndrome. Which interventions should the nurse incorporate in the plan for this client?
Explanation
Choice A rationale
The use of silicone-based vaginal lubricants is recommended for clients with Sjögren’s syndrome to alleviate vaginal dryness and discomfort during intercourse.
Choice B rationale
Using dehumidifiers in the home is not recommended for clients with Sjögren’s syndrome, as it can exacerbate dryness in the eyes, mouth, and other mucous membranes.
Choice C rationale
The use of artificial tears is essential for clients with Sjögren’s syndrome to relieve dry eyes and prevent complications such as corneal ulcers.
Choice D rationale
The use of contact lenses is not recommended for clients with Sjögren’s syndrome, as it can further irritate dry eyes and increase the risk of eye infections.
A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
Explanation
Choice A rationale
Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.
Choice B rationale
Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.
Choice C rationale
Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.
Choice D rationale
Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.
A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect?
Explanation
Choice A rationale
Dysphagia, or difficulty swallowing, is not a common manifestation of acoustic neuroma. It is more commonly associated with conditions affecting the throat or esophagus.
Choice B rationale
Apraxia, a motor disorder caused by damage to the brain, is not typically associated with acoustic neuroma. It affects the ability to perform coordinated movements.
Choice C rationale
Vertigo, or a sensation of spinning, is a common manifestation of acoustic neuroma. The tumor affects the vestibular nerve, which is responsible for balance and spatial orientation.
Choice D rationale
Diplopia, or double vision, is not a common symptom of acoustic neuroma. It is more often associated with conditions affecting the muscles or nerves controlling eye movement.
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