ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Admission Assessments: Client admitted to labor and delivery. Gravida 1, para 0 at 40 weeks of gestation, presents with contractions every 5 to 6 min, 30 to 40 seconds duration, 2+ intensity. Client reports their water broke and the fluid was clear. Positive for group B Streptococcus B-hemolytic at 37 weeks. Sterile vaginal examination. Cervix 5 cm dilated, 50% effaced, and 0 station. Flow Sheet: 1130:
Fetal heart rate 140/min with moderate variability. Intermittent accelerations. Contractions moderate, average 80 seconds duration.
1210:
Fetal heart rate 140/min with moderate variability. Early deceleration. Contractions moderate, average 90 seconds duration.
1215:
Fetal heart rate 120/min with minimal variability Early decelerations. Vital Sign:1130:
Temperature 36.4° C (97.5° F)
Heart rate 84/min
Respiratory rate 18/min
BP 124/82 mm Hg
1200:
Temperature 36.5° C (97.7° F)
Heart rate 90/min.
Respiratory rate 18/min
BP 128/84 mm Hg
1215:
Temperature 37.1° C (98.8° F)
Heart rate 86/min
Respiratory rate 18/min
BP 120/80 mm Hg
Question 1 of 5
The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client: A. Decrease the IV flow rate, B. Monitor fetal heart rate, C. Administer ampicillin IV, D. Place client in left lateral position, E. Request a prescription for ephedrine.
| Options | Essential | Contrainidication |
|---|---|---|
| Decrease the IV flow rate | ||
| Monitor fetal heart rate | ||
| Administer ampicillin IV | ||
| Place client in left lateral position | ||
| Request a prescription for ephedrine |
Correct Answer:
Rationale:
To determine the correct answer, we must consider the implications of an epidural insertion. Decreasing the IV flow rate is essential to prevent hypotension which can occur due to the epidural anesthesia. Monitoring fetal heart rate is essential to ensure fetal well-being. Administering ampicillin IV and requesting ephedrine are not directly related to the client's condition post-epidural, so they are contraindicated. Placing the client in the left lateral position helps to optimize blood flow to the placenta and is essential post-epidural.
Therefore, the correct answer is .
Extract:
Question 2 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 correct answer is C: The child was brought to the ED 2 days after the injury occurred. This delay in seeking medical attention for a fractured arm raises concerns about potential child maltreatment. Delayed medical care can indicate neglect or intentional harm. This warrants further investigation by the nurse to ensure the child's safety.
Choice A is incorrect because it is common for guardians to accompany children to medical procedures.
Choice B is common in accidental injuries and does not necessarily indicate maltreatment.
Choice D is a normal response to pain and does not directly suggest maltreatment.
Question 3 of 5
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Select a site proximal to previous venipuncture sites. This is important to prevent complications like phlebitis and infiltration. Choosing the client's dominant arm (
A) may not always be necessary. Initiating IV access on the palmar side of the wrist (
C) is not ideal due to the risk of nerve damage. Inserting a larger gauge IV catheter (
D) can increase the risk of phlebitis and should be avoided unless necessary.
Question 4 of 5
A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Position the client on their side. This is crucial to prevent aspiration in case the client vomits post-seizure. Placing the client on their side helps maintain a clear airway and prevents choking. Restraints (
A) should not be used unless absolutely necessary for safety. Ambulating (
B) a client after a seizure is unsafe as they may be disoriented or weak. Raising all side rails (
D) can restrict access for emergency care.
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: The correct answer is B: Acute hemolytic transfusion reaction. This type of reaction occurs when there is a mismatch between the donor and recipient blood types, leading to the rapid destruction of the infused red blood cells. The symptoms presented by the client, such as chills, headache, low-back pain, and chest tightness, are indicative of a severe immune response causing the release of cytokines and other inflammatory mediators. It is crucial for the nurse to recognize these signs promptly as this reaction can be life-threatening if not addressed immediately.
Other choices are incorrect because:
A: Allergic reactions typically present with symptoms like itching, hives, and mild respiratory distress, not the severe symptoms described in the scenario.
C: Bacterial reactions occur due to contaminated blood products and usually manifest with fever, chills, and hypotension, rather than the specific symptoms mentioned.
D: Febrile nonhemolytic reactions are characterized by fever and chills, without the additional symptoms