ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?
Correct Answer: Transverse fetal lie contraindicates misoprostol due to risks like cord prolapse. Other conditions may warrant its use.
Rationale: The correct answer is B: Transverse fetal lie. Misoprostol is contraindicated in cases of transverse fetal lie due to the risk of cord prolapse, which can lead to serious complications during labor. In transverse lie, the baby is positioned sideways in the uterus, increasing the likelihood of the umbilical cord slipping down before the baby, cutting off their oxygen supply. This situation requires immediate intervention, usually through a cesarean section.
Preeclampsia (choice
A), post-term pregnancy (choice
C), and intrauterine growth restriction (choice
D) are not contraindications for misoprostol administration. In fact, misoprostol may be used in these conditions to induce labor when necessary.
In summary, the presence of a transverse fetal lie poses a significant risk of cord prolapse and subsequent complications during labor, making it a contraindication for the use of misoprostol in this scenario.
Question 2 of 5
While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?
Correct Answer: A high-pressure alarm indicates airway obstruction, often from secretions. Suctioning clears the airway. Tracheostomy, tightening connections, or checking for cuff leaks are not the priority.
Rationale: The correct answer is B: Suction the client's airway. When a high-pressure alarm sounds on a ventilator, it typically indicates airway obstruction, often due to secretions. Suctioning the client's airway helps to clear any blockages and restore proper airflow, addressing the immediate issue causing the alarm. This action is crucial in maintaining the client's respiratory function and preventing further complications. Requesting insertion of a tracheostomy tube (
A) is not the first-line intervention for airway obstruction in this scenario. Tightening tubing connections (
C) or looking for a leak in the tube's cuff (
D) are not immediate actions to address the alarm. The priority is to clear the airway obstruction promptly to ensure adequate ventilation and oxygenation for the client.
Question 3 of 5
A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, 'I'm afraid they will give me drugs that put me to sleep.' Which of the following statements should the nurse make?
Correct Answer: Respecting the right to refuse medications validates the client's autonomy, fostering trust. Other responses dismiss concerns or undermine rights.
Rationale: The correct answer is B. Respecting the right to refuse medications is crucial in honoring the client's autonomy and building trust. By acknowledging the client's fear and ensuring that their wishes are respected, the nurse demonstrates empathy and promotes a therapeutic relationship.
Choice A dismisses the client's concerns and focuses solely on rest, ignoring the client's autonomy.
Choice C undermines the client's rights and dismisses their fears.
Choice D does not directly address the client's fear and instead questions their provider's intentions. Overall, choice B is the most appropriate response as it aligns with ethical principles of autonomy and respect for the client's choices.
Question 4 of 5
A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications?
Correct Answer: Flumazenil reverses benzodiazepine toxicity. Atropine, naloxone, and charcoal are for other conditions.
Rationale: The correct answer is B: Flumazenil. Flumazenil is a benzodiazepine receptor antagonist that reverses the effects of benzodiazepine toxicity by competitively inhibiting the binding of benzodiazepines at the receptor sites. Atropine is used for treating bradycardia and organophosphate poisoning. Naloxone is used for opioid overdose reversal. Activated charcoal is used for poisoning by ingestion to absorb toxins.
Therefore, the correct choice is Flumazenil as it specifically targets benzodiazepine toxicity.
Question 5 of 5
A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
Correct Answer: Positive airflow can spread measles; negative airflow is required. N95 use, airborne precautions, and masks during transport are correct.
Rationale: The correct answer is C. Positive airflow can spread measles; negative airflow is required to prevent transmission.
Step 1: Measles is highly contagious and spreads through droplets in the air.
Step 2: Positive airflow can push contaminated air out of the room, potentially spreading the virus.
Step 3: Negative airflow creates a vacuum effect, preventing contaminated air from escaping the room.
Step 4:
Therefore, maintaining positive airflow in the client's room would not contain the measles virus and could lead to transmission to others. The other choices (A, B,
D) are correct because wearing an N95 respirator, placing the client on airborne precautions, and having the client wear a mask during transport all help prevent the spread of measles.