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 at 32 weeks of gestation and has deep-vein thrombosis. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Measure and record the client's leg circumferences daily. This is essential in monitoring for changes in swelling, which can indicate worsening deep-vein thrombosis. This action helps in early detection of complications. Option B is incorrect as it can increase the risk of thrombus dislodgement. Option C is irrelevant as monitoring RBCs does not directly address the client's condition. Option D is contraindicated in pregnancy due to the risk of fetal harm.
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 2 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 3 of 5
A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Small clots with tissue in the urine. After a transurethral resection of the prostate, it is common to see small clots with tissue in the urine due to the trauma caused by the procedure. This finding is expected as the body heals postoperatively.
Incorrect Answers:
B: Dark red urine would indicate active bleeding, which is not a normal finding in this situation.
C: Urinary output of 25 mL/hr is below the normal range and may indicate inadequate hydration or potential kidney issues, not a typical finding postoperatively.
D: Pain of 8 on a scale of 0 to 10 is a high level of pain and should be addressed promptly, but it is not a typical finding associated with this specific postoperative period.
Question 4 of 5
A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?
Correct Answer: B
Rationale: The correct answer is B: A child who has bacterial meningitis. Seizure precautions should be initiated for this client due to the risk of seizures associated with meningitis. Bacterial meningitis can lead to increased intracranial pressure, inflammation of the brain, and potential neurological complications, all of which can trigger seizures. Seizure precautions are necessary to prevent injury during a seizure episode.
Incorrect options:
A: An infant with respiratory syncytial virus does not typically require seizure precautions as RSV primarily affects the respiratory system.
C: An infant with hypertrophic pyloric stenosis may not be at immediate risk of seizures unless there are complications.
D: A child with Kawasaki disease typically does not present with seizures as a primary symptom.
Question 5 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.