ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Question 1 of 5
A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?
Correct Answer: C
Rationale: The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation. The guardian wanting to accompany the child is typical parental behavior. A fall from a swing is a plausible explanation, though it should be verified. Crying due to pain is expected with a fracture and not indicative of maltreatment.
Extract:
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours ago and is a greenish color." Client also reports contractions began about 4 hr ago and have become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad. Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min. Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
Question 2 of 5
A nurse in an antepartum unit is caring for a client., For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia: A. Purulent amniotic fluid, B. Elevated uric acid level, C. Fever, D. Decreased platelet count, E. Blurred vision.
Correct Answer: A,C,B,D,E
Rationale: Purulent amniotic fluid and fever are consistent with chorioamnionitis, indicating infection. Elevated uric acid level, decreased platelet count, and blurred vision are consistent with preeclampsia, related to endothelial dysfunction and organ involvement. Each finding is correctly categorized based on disease pathology.
Extract:
Question 3 of 5
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?
Correct Answer: D
Rationale: Nervousness. Low blood glucose triggers the release of epinephrine, leading to symptoms such as nervousness, tremors, and sweating. Tachypnea and ketonuria are associated with diabetic ketoacidosis, not hypoglycemia. Hypoglycemia causes cool, clammy skin, not warm skin.
Question 4 of 5
A nurse is evaluating the progress of a school-age child who takes methylphenidate. Which of the following findings indicates the effectiveness of the medication?
Correct Answer: A
Rationale: Decreased impulsiveness. Methylphenidate treats ADHD by improving impulse control. Abdominal pain resolution, increased appetite, or urine output are not indicators of effectiveness.
Question 5 of 5
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of 'tightness' in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?
Correct Answer: B
Rationale: Acute hemolytic. This reaction occurs when the client receives incompatible blood, leading to red blood cell destruction. Symptoms include chills, headache, low-back pain, chest tightness, hypotension, and fever. Allergic reactions typically involve itching and rash. Bacterial reactions involve fever and sepsis. Febrile nonhemolytic reactions lack low-back pain and chest tightness.