ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?
Correct Answer: D
Rationale: The correct answer is D: Abdominal distention. Paralytic ileus is a temporary lack of movement in the intestines that can occur after surgery. Abdominal distention is a common sign of paralytic ileus due to the buildup of gas and fluid in the intestines. Watery stool (
A) is not indicative of paralytic ileus as it suggests normal bowel function. Oliguria (
B) refers to decreased urine output and is not directly related to paralytic ileus. Dizziness (
C) is a nonspecific symptom and not typically associated with paralytic ileus.
Question 2 of 5
A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A. Acute epiglottitis is a medical emergency that can lead to airway obstruction. The nurse should assess this child first to ensure airway patency. Drooling is a sign of difficulty swallowing and impending airway compromise. The nurse should act promptly to prevent respiratory distress.
Choices B, C, and D do not present immediate life-threatening conditions that require urgent assessment. Bright red blood in urine in a child with a UTI may indicate a more severe infection, but it does not require immediate intervention like airway management. Severe fatigue in a child with mononucleosis and an abdominal mass in a child with Wilms' tumor are concerning, but they do not pose immediate threats to the child's airway.
Question 3 of 5
While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Suction the client's airway. When the high-pressure alarm on the ventilator sounds, it indicates that there is an obstruction in the airway. Suctioning helps to clear the airway and prevent further complications. Looking for a leak in the tube's cuff (
B) is not the priority in this situation. Tightening tubing connections (
C) may not address the immediate issue of airway obstruction. Requesting insertion of a tracheostomy tube (
D) is not necessary unless other interventions fail.
Question 4 of 5
A nurse is reviewing the results of laboratory screenings for a 9-month-old infant. Which of the following results should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Lead 18 mcg/dL. Elevated lead levels in infants can lead to developmental delays and neurocognitive impairments. Lead poisoning is a serious concern, and any detectable lead levels should be reported to the provider for further evaluation and intervention.
Choices A, B, and D are within normal ranges for a 9-month-old infant and do not raise immediate concerns. Reporting these values would not be necessary.
Question 5 of 5
A nurse is caring for a client who has a new prescription for spironolactone and reports that he forgot to tell the provider that he takes over-the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?
Correct Answer: B
Rationale: The correct answer is B: Potassium. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium. If the client takes potassium supplements along with spironolactone, it can lead to dangerously high levels of potassium in the blood (hyperkalemia), which can be life-threatening.
Therefore, the client should avoid taking additional potassium supplements while on spironolactone.
Incorrect options:
A: Calcium - Calcium supplements do not interact significantly with spironolactone.
C: Iron - Iron supplements do not interact significantly with spironolactone.
D: Magnesium - Magnesium supplements do not interact significantly with spironolactone.