ATI CAPSTONE FUNDAME NTALS, ATI
FUNDAMENTALS EXAM, C APSTONE TEST
BANK, ATI VERIFIED ANSWERS,
NURSING FUNDAMENTALS ATI, ATI
PRACTICE QUESTIONS, ATI CAPSTONE
STUDY GUIDE
Question : The emergency department triage nurse receives
notification there has been a mass shooting incident at a local shopping mall with several casualties injured. The hospital’s emergency response plan is initiated. Which client should the nurse prioritize for care?(a) Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.(b) Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.(c) Client with superficial lacerations to the left arm and left lower leg.(d) Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale.
CORRECT ANSWER: A. Client with a sucking chest
wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
RATIONALE:
A sucking chest wound compromises breathing, causes tension pneumothorax, and decreases cardiac output.Hypotension (88/58 mm Hg) and tachycardia (115/min) indicate shock, warranting immediate intervention. Red tag signifies life-threatening but potentially survivable injuries.
Question : The nurse should identify that Client 1 requires
priority care due to which of the following reasons?(a) The client has severe but survivable injuries.(b) The client has minor injuries requiring immediate care.(c) The client has non-life-threatening injuries but requires follow-up care.(d) The client has injuries that do not require urgent attention.
CORRECT ANSWER: A. The client has severe but
survivable injuries.
RATIONALE:
Severe but survivable injuries demand immediate care to stabilize critical functions like airway, breathing, and circulation. Prioritizing care ensures better survival outcomes, especially with red tag cases requiring prompt medical intervention.
Question : Which client should receive immediate
intervention based on the following details?
(a) Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.(b) Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.(c) Client with superficial lacerations to the left arm and left lower leg, occlusive dressing in place, tearful, blood pressure 118/78 mm Hg, and green tag observed.(d) Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale, and yellow tag observed.
CORRECT ANSWER: A. Client with a sucking chest
wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
RATIONALE:
Sucking chest wounds impair oxygenation, posing a direct threat to life. Signs of shock (88/58 mm Hg, heart rate 115/min) demand immediate intervention. Red tag classification reflects life-threatening but treatable conditions needing priority care.
Question : Which prescription should the nurse clarify with
the provider prior to administration?(a) Potassium Chloride 20 mEq PO daily.(b) HCTZ 25 mg PO daily.
(c) Amlodipine 10 mg PO daily.(d) Clonidine 1 mg PO TID PRN for systolic blood pressure of 180.
CORRECT ANSWER: D. Clonidine 1 mg PO TID PRN for
systolic blood pressure of 180.
RATIONALE:
Clonidine 1 mg TID PRN for systolic blood pressure above 180 is excessive. Normal doses are 0.1-0.3 mg. High doses risk severe hypotension, bradycardia, and withdrawal symptoms. This requires clarification.
Question : A nurse is caring for a client in the emergency
department. Which action should the nurse take based on the client’s medication administration record at 1130?(a) Administer Albuterol nebulizer 2.5 mg stat.(b) Administer Methylprednisolone 50 mg IV stat.(c) Reassess the client’s vital signs before administering medications.(d) Notify the provider if the client has worsening symptoms after administration.
CORRECT ANSWER: C. Reassess the client’s vital signs
before administering medications.
RATIONALE:
vital signs ensures the patient's stability before administering medications. This is vital in emergencies to evaluate therapy needs and prevent further clinical deterioration.