ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?
Correct Answer: D
Rationale: The correct answer is D. Referring to oneself by name at 24 months is a developmental milestone indicating self-awareness and language development. It shows understanding of personal identity.
Choices A, B, and C are typical gross motor skills for a 24-month-old. Falling when throwing a ball overhand is expected as motor skills are still developing. Going up stairs with two feet on each step is a common way toddlers climb stairs for safety. Running with a wide stance is normal at this age for balance and stability.
Question 2 of 5
A nurse is planning postoperative care for a client who is having a thoracotomy with a chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?
Correct Answer: C
Rationale: The correct answer is C: Padded clamp. The nurse should have a padded clamp at the client's bedside to secure the chest tube in place and prevent accidental dislodgement. Wire cutters (
A) are not necessary for thoracotomy care. Tracheostomy tray (
B) is used for tracheostomy care, not chest tube placement. Sand bag (
D) is not needed for a thoracotomy with chest tube placement.
Question 3 of 5
A nurse on a medical-surgical unit is accepting a telephone prescription for a client who requires medication for insomnia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A. Repeating the complete prescription back to the provider ensures accuracy and prevents errors in transcription. This step verifies understanding and allows the provider to confirm the details.
Choice B involves unnecessary steps as the prescription is over the phone.
Choice C involves a non-clinical staff in a clinical task.
Choice D is important but comes after confirming with the provider.
Question 4 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: B
Rationale: The correct answer is B: Administer the mixture within 5 min of preparing it. This is important because regular insulin should always be drawn up before NPH insulin due to the risk of contaminating the regular insulin with NPH. Administering the mixture promptly ensures the insulin remains stable and effective.
Choice A is incorrect because shaking the vials can cause air bubbles and lead to inaccurate dosing.
Choice C is incorrect as NPH insulin should be drawn up after regular insulin to avoid contamination.
Choice D is incorrect as air should be injected into the vial after withdrawing insulin to prevent creating a vacuum.
Question 5 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: A
Rationale:
Correct Answer: A
Rationale: The nurse should respect the client's autonomy and right to refuse medications, especially in the case of involuntary admission. By acknowledging and respecting the client's fear of being given sedating drugs, the nurse establishes trust and promotes open communication. This approach empowers the client and fosters a therapeutic relationship. It also aligns with ethical principles of beneficence and non-maleficence by prioritizing the client's wishes and well-being.
Summary of Incorrect
Choices:
B: This response dismisses the client's concerns and does not address the fear of being given sedating drugs.
C: This response does not validate the client's fear and may come across as confrontational.
D: This response is authoritarian and disregards the client's autonomy and right to participate in treatment decisions.