ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?
Correct Answer: A
Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.
Question 2 of 5
A client with a new prescription for sumatriptan tablets to treat migraine headaches should report which of the following symptoms to the nurse?
Correct Answer: B
Rationale: The correct answer is B because swelling of the eyelids is a side effect of sumatriptan tablets that requires immediate reporting to the healthcare provider to prevent further complications. Choices A, C, and D are incorrect. Chewing the tablet well before swallowing is not necessary for sumatriptan tablets. Repeating the dose in 1 hour for unrelieved headache is incorrect as this medication should not be repeated within 24 hours. Taking sumatriptan daily for headache prevention is also incorrect as it is used for acute treatment, not prevention.
Question 3 of 5
A client with cirrhosis and ascites requires a care plan. Which intervention should the nurse include?
Correct Answer: D
Rationale: In cirrhosis with ascites, decreasing fluid intake is crucial to manage the condition. This helps prevent further fluid accumulation in the abdomen. Increasing sodium intake (Choice A) can worsen fluid retention and edema. Increasing saturated fat intake (Choice B) is not recommended as it can contribute to liver damage. Decreasing carbohydrate intake (Choice C) is not directly related to managing ascites in cirrhosis.
Question 4 of 5
A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C. Clear fluid draining from the ear may indicate a cerebrospinal fluid (CSF) leak, which is a serious complication following a head injury. Reporting this finding is crucial as it may require immediate medical intervention to prevent further complications. Choices A, B, and D are not as concerning as a CSF leak. A GCS score of 12 is relatively high, indicating a mild level of consciousness alteration. An edematous bruise on the forehead is a common physical finding after a head injury. Pupils that are 4 mm and reactive to light suggest normal pupillary function.
Question 5 of 5
A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.