ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Vital Signs
2000:
Temperature 36.7° C (98.1° F).
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 128/84 mm Hg
Oxygen saturation 98% on room air
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours ago and is a greenish color." Client also reports contractions began about 4 hr ago and have become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad. Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min. Vaginal examination performed: cervix 4 cm dilated, 70% effaced, O station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
Question 1 of 5
A nurse in an antepartum unit is caring for a client.Exhibits Select the 2 findings that require immediate follow-up.
Correct Answer: B,D
Rationale: The correct answers are B (Fetal heart rate) and D (Characteristics of amniotic fluid) because these findings are critical indicators of fetal well-being. Changes in fetal heart rate may indicate fetal distress, requiring immediate intervention. Monitoring amniotic fluid characteristics is crucial to assess for potential complications like infection or rupture. Blood pressure, fetal station, and contraction duration are important but not as urgent as fetal heart rate and amniotic fluid assessment in this context.
Extract:
Question 2 of 5
A nurse manager is reviewing medical records to recommend clients for discharge following a local mass casualty event. Which of the following clients should the nurse recommend for discharge?
Correct Answer: D
Rationale: The correct answer is D: A client who is scheduled to have a colonoscopy in 12 hr. This client should be recommended for discharge as they are stable and well enough to undergo a scheduled procedure that is not urgent, indicating their condition is not critical. The other choices are incorrect because: A: Heart failure with recent furosemide administration may require monitoring. B: Chest pain admission 24 hr ago may indicate ongoing evaluation and treatment. C: Seizure 48 hr ago with seizure precautions still needed for safety. In summary, choice D is the best option for discharge given the client's scheduled non-urgent procedure and stable condition.
Question 3 of 5
A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?
Correct Answer: D
Rationale:
Correct Answer: D
Rationale: Injecting air into the regular insulin vial before the NPH insulin vial prevents contamination. This technique avoids drawing NPH insulin into the regular insulin vial, which could alter the regular insulin's effectiveness. It also prevents air bubbles from being injected into the NPH vial, which could affect the accuracy of the NPH insulin dosage.
Summary of other choices:
A: Shaking both insulin vials before withdrawing doses can cause frothing and denaturation of insulin molecules, affecting their efficacy.
B: Administering the mixture within 5 minutes is not a recommended practice as it does not address the issue of potential contamination between the two insulins.
C: Withdrawing NPH insulin before regular insulin can lead to contamination and inaccurate dosages.
E, F, G: No information provided.
Question 4 of 5
A nurse is preparing to administer heparin at 1,000 units/hr via continuous IV infusion to a client who had a coronary artery bypass graft. Available is heparin 25,000 units in dextrose 5% in water in 250 mL. The nurse should set the IV pump to deliver how many mL/hr?
Correct Answer: 10
Rationale: The correct answer is 10 mL/hr.
To calculate this, first determine the total units in the bag (25,000 units).
Then, divide this by the desired dose rate (1,000 units/hr) to get 25 hours. Next, divide the total volume of the bag (250 mL) by the total time in hours to get 10 mL/hr. This ensures the client receives the correct dose of heparin over the specified time. Other choices are incorrect because they do not follow the correct calculation method or do not result in the precise dosage required for the client's condition.
Question 5 of 5
A nurse is teaching a client who has major depressive disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client?
Correct Answer: C
Rationale: The correct answer is C: You might feel a bit confused for a few hours after the procedure. This is because confusion is a common side effect of electroconvulsive therapy (ECT) due to the temporary disruption of cognitive functions. The confusion typically resolves within a few hours post-procedure.
Choice A is incorrect because feeling pulsations in the neck is not a typical sensation experienced during ECT.
Choice B is incorrect as the client usually wakes up shortly after the procedure, not 30 minutes later.
Choice D is incorrect as changes in voice are not a common side effect of ECT.