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, 0 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.
2020:
Question 1 of 5
A nurse in an antepartum unit is caring for a client. For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client: A. Initiate an IV infusion of lactated Ringer's, B. Place the client in a left lateral position, C. Monitor blood pressure every hour, D. Maintain continuous monitoring of the FHR.
Correct Answer: A,B,D
Rationale: Initiate an IV infusion of lactated Ringer’s, place the client in a left lateral position, and maintain continuous FHR monitoring are anticipated to support hydration, perfusion, and fetal monitoring. Monitoring blood pressure every hour is contraindicated; more frequent monitoring is needed due to hypertension and gestational diabetes risks.
Extract:
Question 2 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: Post-procedure confusion is a common, temporary side effect of ECT. Pulsations, 30-minute awakening, or voice changes are not expected.
Question 3 of 5
A nurse is implementing crisis intervention for a client following an incident of partner violence. Which of the following is the priority action for the nurse to take?
Correct Answer: B
Rationale: Ensuring the client’s immediate safety is the priority to protect from further harm. Coping skills, support systems, and expressing feelings are secondary to safety.
Question 4 of 5
A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?
Correct Answer: D
Rationale: Rotavirus vaccine is given at 2 months. Varicella, influenza, and hepatitis A are administered at later ages.
Question 5 of 5
A nurse is assessing a client who is in mechanical restraints after hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?
Correct Answer: C
Rationale: The client is able to calmly follow commands. This indicates self-control and reduced risk of harm, allowing restraint discontinuation. Duration, insight, or discomfort do not solely justify removal.