ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN Questions
Question 1 of 5
A client has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?
Correct Answer: D
Rationale: In this scenario, the correct answer is option D, grape juice. A clear liquid diet is prescribed for clients who need easy-to-digest foods that leave little residue in the gastrointestinal tract. Grape juice is a suitable choice because it is clear and does not contain solid particles. Option A, lemon sherbet, contains solid particles from the frozen dessert, which may not be appropriate for a clear liquid diet. Option B, milkshake, is a thick liquid that contains dairy and solid particles, making it unsuitable for a clear liquid diet. Option C, vanilla ice cream, is a frozen dairy product with solid particles and is not considered a clear liquid. Educationally, understanding the components of different diet types is crucial for nurses when caring for patients with specific dietary requirements. It is essential for nurses to know the characteristics of a clear liquid diet to ensure that patients receive appropriate nutrition while meeting their medical needs. This knowledge helps in promoting patient safety and well-being during their recovery process.
Question 2 of 5
A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?
Correct Answer: D
Rationale: The correct answer is D. Tilting the head forward during swallowing is not a compensatory technique for dysphagia and may increase the risk of aspiration. Choices A, B, and C are correct statements indicating appropriate monitoring for manifestations of dysphagia: coughing while eating, pocketing food in the mouth, and changes in voice after swallowing are all signs that should be monitored.
Question 3 of 5
A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C: Oxygen saturation. Following abdominal surgery, the priority assessment is to ensure adequate oxygenation. Monitoring oxygen saturation is crucial as the client may be at risk of respiratory complications due to the effects of anesthesia, pain medications, and the surgical procedure itself. Assessing urinary output is important for monitoring kidney function but is not the priority immediately postoperatively. Pain level assessment is essential for the client's comfort but does not take precedence over ensuring oxygen saturation. Checking the abdominal dressing is important for wound assessment, but ensuring adequate oxygenation is the priority in the immediate postoperative period.
Question 4 of 5
A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Perform a bladder scan. The rationale behind this choice is to assess the client's bladder volume non-invasively before considering other interventions. A bladder scan will provide essential information on the need for catheterization and help determine if the client is in urinary retention, guiding further management. Option A) Provide assistance to the bathroom is incorrect as the client may have urinary retention, making it ineffective. Option B) Insert a straight catheter is invasive and should not be the first action without assessing the bladder first. Option C) Increase fluids may exacerbate the problem if the client is in urinary retention. Educationally, understanding the importance of timely bladder assessment in clients who have not voided post-catheter removal is crucial for nurses. It highlights the significance of using non-invasive measures like bladder scans to guide appropriate interventions, promoting patient safety and effective care delivery.
Question 5 of 5
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
Correct Answer: D
Rationale: The correct answer is D, poor impulse control. Right hemisphere strokes commonly affect judgment and safety awareness, leading to poor impulse control. Choices A, B, and C are incorrect for this scenario. Deficits in the right visual field are associated with left hemisphere strokes, while the inability to discriminate words and letters is typically seen with left hemisphere damage. Motor retardation is more common in strokes affecting the motor areas of the brain, not specifically related to right hemisphere strokes.