ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: 4+ deep-tendon reflexes. Postpartum women may experience hyperactive deep-tendon reflexes, which could indicate preeclampsia or eclampsia. The nurse should report this finding promptly to the provider for further evaluation and management. Scant lochia rubra with a few small clots (
A) is expected in the early postpartum period. Urine output of 2,500 mL/day (
B) is within normal range. Bilateral ankle edema (
C) can be common postpartum due to fluid shifts.
Therefore, it is not a concerning finding.
Question 2 of 5
A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is important to create a seal that prevents air from entering the pleural space. If the water level is too high or too low, it can affect the functioning of the chest tube system.
Choice B is incorrect as checking tubing patency every 2 hours is not necessary unless there are signs of blockage or decreased drainage.
Choice C is incorrect as the drainage system should be kept below the level of the client's chest to facilitate drainage by gravity.
Choice D is incorrect as the collection chamber should be emptied as needed based on the amount of drainage, not on a fixed time schedule.
Question 3 of 5
A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: D
Rationale: The correct answer is D: Instruct visitors to stay 1 m (3.3 feet) away from the client. This is important in brachytherapy to minimize radiation exposure to others. Keeping a safe distance helps reduce the risk of radiation exposure. Straining the client's urine (
A) is not necessary for brachytherapy. Limiting visitors' time (
B) does not directly relate to radiation safety. Attaching a dosimeter (
C) is not typically done with low-dose radiation implants.
Therefore, the best choice is D to ensure visitor safety.
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 4 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 5 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.