ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like 'something opened up.' The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Cover the wound with a saline-soaked dressing. This action is appropriate because it helps to prevent further damage to the exposed intestinal tissue and maintains a moist environment to promote healing. Placing the client in Trendelenburg position (
A) is not recommended as it can increase intra-abdominal pressure and worsen the situation. Reinserting the protruding intestinal tissue (
B) should not be done by the nurse as it can lead to complications and is beyond the scope of nursing practice. Monitoring vital signs every 30 minutes (
D) is important but not the immediate priority in this situation where wound coverage is crucial.
Question 2 of 5
A nurse is assessing a client who is taking digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?
Correct Answer: D
Rationale: The correct answer is D: Blurred vision indicates digoxin toxicity. Digoxin toxicity can cause visual disturbances, such as blurred or yellow-tinted vision. This is due to the drug's effects on the optic nerve. Tachycardia (
A) is not a common sign of digoxin toxicity; in fact, digoxin usually slows the heart rate. Hearing loss (
B) and insomnia (
C) are not typical symptoms of digoxin toxicity. Blurred vision is a key indicator of digoxin toxicity and should prompt immediate action to prevent further complications.
Question 3 of 5
A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale:
Correct Answer: A - Report sudden, persistent headaches
Rationale: Sudden, persistent headaches in a child with sickle cell anemia could indicate a serious complication such as a stroke. Immediate medical attention is crucial to prevent further complications. Reporting symptoms promptly can lead to timely interventions and prevent life-threatening situations.
Summary of Incorrect
Choices:
B: Restricting fluid intake during times of stress is not recommended for children with sickle cell anemia as adequate hydration helps prevent dehydration and complications.
C: Applying cold compresses to painful areas may provide temporary relief, but it does not address the underlying cause of pain in sickle cell anemia.
D: Meningococcal immunizations are important for children with sickle cell anemia to prevent infections, so avoiding them is not recommended.
Question 4 of 5
A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, 'I'm afraid they will give me drugs that put me to sleep.' Which of the following statements should the nurse make?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: The nurse should respect the client's autonomy and right to refuse medications, especially in the case of involuntary admission. By acknowledging and respecting the client's fear of being given sedating drugs, the nurse establishes trust and promotes open communication. This approach empowers the client and fosters a therapeutic relationship. It also aligns with ethical principles of beneficence and non-maleficence by prioritizing the client's wishes and well-being.
Summary of Incorrect
Choices:
B: This response dismisses the client's concerns and does not address the fear of being given sedating drugs.
C: This response does not validate the client's fear and may come across as confrontational.
D: This response is authoritarian and disregards the client's autonomy and right to participate in treatment decisions.
Question 5 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.