ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has diabetic ketoacidosis. During the shift, the client received 0.45% sodium chloride IV at 500 mL/hr for 3 hr, then at 200 mL/hr for 3 hr, and then dextrose 5% in water at 75 mL/hr for 2 hr. What is the total volume the nurse should document for the client's IV fluid intake? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2250
Rationale: The correct answer is 2250.
To calculate the total volume, you add the volumes from each rate: 0.45% sodium chloride at 500 mL/hr for 3 hr (500*3=1500 mL), then at 200 mL/hr for 3 hr (200*3=600 mL), and finally dextrose 5% in water at 75 mL/hr for 2 hr (75*2=150 mL). Adding these together (1500+600+150=2250 mL) gives the total fluid intake. The other choices are incorrect as they do not accurately calculate the total volume based on the rates and durations provided.
Question 2 of 5
A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C: Scrambled eggs. This food choice is appropriate for a client with dysphagia caused by a stroke because it is soft and easy to swallow, reducing the risk of aspiration. Scrambled eggs are also a good source of protein and nutrients.
A: Crispy rice bar is not recommended as it is hard and can pose a choking hazard for someone with dysphagia.
B: Soda crackers are dry and can be difficult to swallow without enough liquid, increasing the risk of choking.
D: Peanut butter is thick and sticky, making it challenging for someone with dysphagia to swallow safely.
In summary, scrambled eggs are the best choice due to their soft texture and nutritional value, while the other options pose potential risks for individuals with dysphagia.
Question 3 of 5
A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client about the use of telehealth services. This is the most appropriate intervention as it allows the nurse to monitor the client's diabetes management remotely, provide education, and support without the need for the client to travel to a healthcare facility frequently. This intervention promotes independent living while ensuring the client receives necessary care.
A: Discussing a long-term care referral may not be appropriate as the client is still living independently.
B: Reviewing assisted living accommodations is premature and not necessary.
C: Suggesting adult day care may not be relevant for a client who is independent and needs diabetes management.
Overall, option D is the best intervention for this scenario.
Question 4 of 5
A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Measure the legs with a tape measure to determine stocking size. This is important to ensure a proper fit and optimal effectiveness in preventing complications related to deep-vein thrombosis. Folding the stockings (choice
A) can create pressure points and impede circulation. Removing the stockings every 24 hr (choice
B) can lead to inadequate compression and increase the risk of blood clots. Massaging the legs before applying the stockings (choice
C) can dislodge blood clots and worsen the condition.
Therefore, measuring the legs with a tape measure is the most appropriate action to provide the client with the correct size of antiembolitic stockings.
Question 5 of 5
A nurse is reviewing the medication administration record of a client who is to undergo excretory urography using contrast dye. The nurse should plan to withhold which of the following medications 24 to 48 hr before the procedure?
Correct Answer: B
Rationale: The correct answer is B: Metformin. This medication should be withheld before excretory urography as contrast dye can affect kidney function, leading to a risk of lactic acidosis when combined with metformin. Acetaminophen (
A) does not interact with contrast dye. Atenolol (
C) and prednisone (
D) are not contraindicated for this procedure. In summary, metformin should be withheld to prevent lactic acidosis, while the other options do not pose the same risk.