ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?
Correct Answer: Cleaning the area around the base of the cord with water helps prevent infection and promotes healing. Covering the cord with a diaper traps moisture, increasing infection risk. Petroleum jelly interferes with drying, and minor bleeding when the stump falls off is normal.
Rationale:
Step 1: Washing the area around the base of the cord with water is the correct instruction because it helps prevent infection by keeping the area clean and promotes healing by removing any debris or bacteria.
Step 2: Covering the cord with the upper edge of the diaper (choice
A) is incorrect as it traps moisture, creating a moist environment that can lead to infection.
Step 3: Applying petroleum jelly around the cord with every diaper change (choice
B) is incorrect as it can interfere with the drying process of the cord, which is essential for it to fall off naturally.
Step 4: Reporting minor bleeding when the cord's stump falls off (choice
C) is incorrect as it is a normal part of the healing process and does not require reporting unless it is excessive.
Step 5: By following the correct instruction (choice G), the client can ensure proper care of the newborn's umbilical cord, promoting healing and reducing the risk of infection.
Question 2 of 5
A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
Correct Answer: Advance directives allow clients to regain control of health care decisions once competency is restored. A surrogate does not have to be a family member, providers do not choose surrogates, and providers are generally obligated to follow advance directives.
Rationale: The correct answer is B. This statement indicates an understanding of advance directives as it correctly states that a client can resume control of health care decisions after a temporary loss of competency. Clients can regain autonomy once they regain competency.
A: Incorrect. A health care surrogate does not have to be a family member. Surrogates can be anyone chosen by the client.
C: Incorrect. The client typically chooses their own health care surrogate, not the provider.
D: Incorrect. Providers are generally obligated to follow advance directives and should not go against the client's wishes.
In summary, choice B is correct because it accurately reflects the concept of regaining control of health care decisions after a temporary loss of competency, while the other choices contain inaccuracies or misunderstandings about advance directives.
Question 3 of 5
A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?
Correct Answer: Telehealth services support diabetes management in rural areas by providing remote monitoring and education, promoting independence. Adult day care, assisted living, or long-term care may not be necessary for an independent client.
Rationale: The correct answer is D: Instruct the client about the use of telehealth services. Telehealth services are essential for remote monitoring and education, crucial for managing diabetes in rural areas. This intervention promotes independence by allowing the client to receive necessary care without needing to attend appointments in person. It also enables timely interventions and support, improving the client's diabetes management.
Choice A is incorrect because attending adult day care may not be necessary for an independent client living in a rural area with type 2 diabetes.
Choice B, reviewing assisted living accommodations, is also incorrect as this level of care is not usually needed for independent older adults with diabetes.
Choice C, discussing a long-term care referral, is unnecessary for a client who is still able to live independently.
In summary, telehealth services are the most appropriate intervention for an older adult with type 2 diabetes living independently in a rural area, as they support diabetes management, promote independence, and provide remote monitoring and education.
Question 4 of 5
A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?
Correct Answer: Corn tortillas and black beans are gluten-free, safe for celiac disease. Rye bread, whole wheat pasta, and barley contain gluten, which is harmful to individuals with celiac disease.
Rationale: The correct answer is B: Corn tortilla with black beans. Corn tortillas and black beans are gluten-free, making them safe for individuals with celiac disease. Gluten is harmful to individuals with celiac disease as it triggers an immune response that damages the small intestine. Rye bread (choice
A), whole wheat pasta (choice
C), and barley (choice
D) all contain gluten and should be avoided by individuals with celiac disease. By recommending corn tortillas with black beans, the nurse ensures that the preschooler's diet is gluten-free and suitable for their condition.
Question 5 of 5
A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?
Correct Answer: Fever may indicate infection, a serious concern with clozapine due to the risk of agranulocytosis. Diaphoresis, polyuria, and diarrhea are less urgent but should be monitored.
Rationale:
Step-by-step rationale:
1. Fever is the correct answer as it may indicate infection, which is a serious concern with clozapine due to the risk of agranulocytosis.
2. Agranulocytosis is a potential side effect of clozapine that can lead to severe neutropenia, increasing the risk of infection.
3. Diaphoresis, polyuria, and diarrhea are less urgent findings that do not directly relate to the risk of agranulocytosis.
4. Diaphoresis is excessive sweating, polyuria is increased urination, and diarrhea are common side effects of clozapine but do not pose an immediate threat like fever does.
5. Reporting fever promptly allows the provider to assess for potential infection and take necessary precautions to prevent complications.