ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a terminal illness. The client tells the nurse, 'I have decided to discontinue my treatment. I want to pursue alternative therapies instead.' Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct response is C: "What has your doctor told you about your treatment options?" This question acknowledges the client's decision and opens up a dialogue about the client's understanding of their current treatment plan. It shows respect for the client's autonomy while also seeking to ensure they have accurate information to make an informed decision.
Choice A may come off as confrontational or judgmental.
Choice B assumes the client hasn't considered their family's input.
Choice D is dismissive and avoids addressing the client's concerns.
Question 2 of 5
A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?
Correct Answer: C
Rationale:
Rationale:
Choice C (Instruct the client to use an overbed trapeze to move around in bed) is correct because it promotes client independence and mobility without putting excessive pressure on the surgical site. This intervention helps prevent complications such as pressure ulcers and deep vein thrombosis. Turning the client every 4 hours (
Choice
A) may be too frequent and could disrupt wound healing. Placing the client on an air mattress (
Choice
B) may not be necessary and could potentially increase the risk of falls. Rewrapping the bandage every 8 hours in a circular pattern (
Choice
D) is incorrect as it can impede circulation and cause complications.
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 3 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:
Correct Answer: A,B,D
Rationale:
A. Initiate an IV infusion of lactated Ringer's: Anticipated because IV fluids help maintain hydration and electrolyte balance, crucial for the pregnant client.
B. Place the client in a left lateral position: Anticipated as this position improves blood flow to the placenta and reduces pressure on the vena cava, enhancing fetal oxygenation.
C. Monitor blood pressure every hour: Not contraindicated, but it is not explicitly stated in the question that it is needed, so it is not the best choice compared to the other options.
D. Maintain continuous monitoring of the FHR: Anticipated as it provides vital information about fetal well-being and helps detect any potential issues promptly.
Extract:
Question 4 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.
Extract:
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.
Question 5 of 5
A nurse in an antepartum unit is caring for a client., For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia: A. Purulent amniotic fluid, B. Elevated uric acid level, C. Fever, D. Decreased platelet count, E. Blurred vision.
Correct Answer: A,C,B,D,E
Rationale: The correct answer is A, C, B, D, E.
A. Purulent amniotic fluid is consistent with chorioamnionitis, an infection of the amniotic fluid and membranes.
C. Fever is a common sign of both chorioamnionitis and preeclampsia but is more specific to chorioamnionitis.
B. Elevated uric acid level is more indicative of preeclampsia due to impaired kidney function.
D. Decreased platelet count is a sign of preeclampsia, indicating potential liver dysfunction.
E. Blurred vision is a hallmark sign of severe preeclampsia due to elevated blood pressure affecting the retina.
Therefore, the correct answer includes findings that are specific to both chorioamnionitis and preeclampsia, providing a comprehensive assessment approach.