ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a sliding hiatal hernia. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Heartburn. In a sliding hiatal hernia, the stomach protrudes through the esophageal hiatus into the chest cavity, leading to acid reflux and heartburn. This occurs when the lower esophageal sphincter weakens, allowing stomach acid to flow back into the esophagus. Breathlessness (
A) is not typically associated with a sliding hiatal hernia unless there is severe compression of the lungs. Abdominal cramping (
C) is more commonly seen with other gastrointestinal issues. Constipation (
D) is unrelated to a hiatal hernia.
Question 2 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.
Extract:
Assessment
1900:
Client presents to the emergency department with a shoulder injury that occurred during a soccer game. Client is unable to elevate or extend their right arm. Client reports pain as 7 on a scale of 0 to 10. Client reports no significant past medical, surgical, or family history.
2000:
Emergency provider, respiratory therapist, and RN at bedside for reduction of right shoulder. Medications administered as prescribed.
Plan of Care
2000:
Plan for moderate sedation for right shoulder reduction.
Question 3 of 5
The nurse should prepare to administer _____ and _____ for a client undergoing shoulder reduction.
Correct Answer: B,C
Rationale: The correct answer is B,C. Naloxone is administered to reverse any opioid-induced respiratory depression during the reduction procedure. Oxygen by face mask at 10 L/min is essential to ensure adequate oxygenation during the procedure. Acetaminophen (choice
A) is a pain reliever but not necessary for this procedure. Fentanyl (choice
D) and propofol (choice E) are potent sedatives that are not typically used for shoulder reduction.
Extract:
Question 4 of 5
A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are 'aging badly' and feel 'so useless.' Which of the following assessment questions is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C: "Do you ever think about harming yourself?" This question is the priority because it assesses the client's immediate safety and risk of harm. The client's statements indicate feelings of worthlessness and fear of aging badly, which can be associated with depression and suicidal ideation in older adults. By asking about thoughts of self-harm, the nurse can identify if the client is at risk and take appropriate actions to ensure their safety.
Choice A (Did anything in particular make you feel this way?) is not the priority because it focuses on the cause rather than the client's safety.
Choice B (Would you tell me more about the changes you see in your body?) is also not the priority as it does not address the client's emotional distress.
Choice D (How long have you had these feelings of uselessness?) is important but not as urgent as assessing for suicidal thoughts.
Question 5 of 5
A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Encourage the child to play with toys such as a pounding board. This is appropriate because play is an essential component of a preschooler's development and can help reduce anxiety during their stay. Providing toys like a pounding board can promote fine motor skills and distract the child from the unfamiliar hospital environment.
Establishing a new routine (choice
A) may cause more stress for the child as they are already in an unfamiliar setting. Using medical terminology (choice
B) can be confusing and intimidating for a preschooler. Performing assessments when the parent is not in the room (choice
D) may not be ideal as the child may feel more comfortable and reassured with their parent present.