ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is assessing an older adult client. Which of the following statements indicates that the client is at a risk for being socially isolated?
Correct Answer: C
Rationale: The correct answer is C. The statement indicates a risk for social isolation because the client is unable to attend church due to a lost hearing aid. This can lead to reduced social interactions and feelings of loneliness.
Choice A does not necessarily indicate social isolation, just potential hearing loss.
Choice B still involves some social interaction.
Choice D shows some social support.
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 2 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 3 of 5
A nurse is assessing a client who has dehydration due to prolonged diarrhea. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Dehydration leads to reduced blood volume, causing hypotension. This occurs due to decreased fluid levels in the body, resulting in lowered blood pressure. Bradycardia (
A) is less likely as the body compensates by increasing the heart rate. Edema (
B) is incorrect as dehydration causes fluid loss, leading to decreased tissue fluid. Crackles (
D) are associated with fluid in the lungs, which is not a common finding in dehydration.
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: The correct answer is D: Rotavirus. At 2 months, infants should receive the rotavirus vaccine to protect against severe diarrhea and dehydration. Rotavirus is a common cause of gastroenteritis in young children. Varicella (
A), Influenza (
B), and Hepatitis A (
C) vaccines are not typically given until the child is older. Providing a summary, Varicella, Influenza, and Hepatitis A vaccines are not recommended for a 2-month-old infant, making them incorrect choices.
Question 5 of 5
A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, 'I don't know what my surgery tomorrow is for.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct answer is B. The nurse should inform the provider that the client has questions about the surgery. This response is appropriate as it ensures the client's concerns are addressed by the healthcare provider who has the necessary expertise to provide detailed information about the upcoming procedure. It promotes effective communication between the client and the healthcare team, leading to a better understanding of the treatment plan.
Choice A is incorrect as simply noting the client's lack of understanding in the medical record does not address the client's immediate need for clarification.
Choice C is incorrect as it suggests discussing alternative treatment options, which may not be relevant if the surgery has already been scheduled.
Choice D is incorrect because the nurse should not provide detailed information about the procedure without involving the healthcare provider, who is responsible for explaining the specifics of the surgery to the client.