ATI RN
ATI Capstone Week 11 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is 'not really sure if she is in labor colp or not.' Which of the following should the nurse recognize as a sign of true labor?
Correct Answer: C
Rationale: The correct answer is C: Changes in the cervix. In true labor, the cervix undergoes changes such as effacement (thinning) and dilation (opening). These cervical changes are indicative of the onset of labor and progression towards childbirth. By assessing the cervix, the nurse can determine if the client is indeed in true labor.
Rupture of the membranes (choice
A) may or may not occur in labor, and it alone does not confirm true labor. The pattern of contractions (choice
B) is important but not sufficient to differentiate true labor from false labor. The station of the presenting part (choice
D) refers to the position of the baby's head in relation to the pelvis and is not a definitive sign of true labor.
Question 2 of 5
A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?
Correct Answer: 1370
Rationale: The correct answer is 1370 mL.
To calculate the client's output, we add the voided urine (400 mL + 350 mL = 750 mL), chest drainage system (175 mL - 155 mL = 20 mL), NG tube drainage (575 mL), and Jackson-Pratt drainage tube (25 mL).
Total output = 750 mL (urine) + 20 mL (chest drainage) + 575 mL (NG tube) + 25 mL (JP tube) = 1370 mL. This total represents all the fluids eliminated by the client during the shift. Other choices are incorrect as they either do not include all the relevant outputs or are calculated incorrectly.
Question 3 of 5
A nursing is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Increase intake of calcium and vitamin D. In Cushing's disease, patients are at risk for osteoporosis due to long-term steroid use. Calcium and vitamin D help support bone health. Increasing carbohydrate intake (
A) is not necessary. Decreasing protein intake (
B) is not recommended as adequate protein is needed for muscle and tissue repair. Limiting potassium-rich foods (
D) is not relevant in Cushing's disease unless the patient has specific kidney issues.
Question 4 of 5
A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching?
Correct Answer: A
Rationale: The correct answer is A because PKU testing does not involve placing the baby under special lights. The test is a simple blood test to check for levels of phenylalanine. Placing the baby under special lights is a treatment for jaundice, not for PKU.
Choice B is correct as PKU can be managed with a special diet low in phenylalanine.
Choice C is accurate as sometimes the test is repeated to confirm the results.
Choice D is also correct as the baby needs to be consuming protein (from formula or breast milk) before the test.
Question 5 of 5
A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because Kegel exercises help strengthen the pelvic floor muscles, which are important for supporting the uterus, bladder, and bowel. Strong pelvic muscles can facilitate the birthing process by providing better control during labor and delivery. Additionally, these exercises can help prevent urinary incontinence postpartum. The other options are incorrect as Kegel exercises do not directly impact stretch marks, back aches, or constipation. Stretch marks are related to skin elasticity, back aches may be relieved through proper posture and exercises targeting back muscles, and constipation is more influenced by dietary factors and hydration.