ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Turn on the faucets in the client's sink. This action helps stimulate the sound of running water, which can aid the client in urinating by triggering the relaxation of the bladder muscles through the auditory cue. Pouring cool water over the perineum (choice
A) may be uncomfortable and not necessarily effective in promoting urination. Instructing the client to stroke her lower abdomen (choice
C) may not directly address the issue of difficulty urinating. Instructing the client to lean slightly backward (choice
D) may not be helpful and could potentially cause discomfort.
Question 2 of 5
A nurse is teaching a client who has a new prescription for levothyroxine (T4) about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?
Correct Answer: C
Rationale: The correct answer is C: Fever. Thyrotoxicosis is a condition characterized by excessive thyroid hormone levels, leading to symptoms such as increased metabolism and body temperature, which can manifest as fever. The client should monitor and report fever as it may indicate worsening of the condition. Weight gain (
A) is not typically associated with thyrotoxicosis, as it usually causes weight loss. Bradycardia (
B) is a symptom of hypothyroidism, not thyrotoxicosis. Drowsiness (
D) is also not a common symptom of thyrotoxicosis, which is more likely to cause insomnia or restlessness.
Question 3 of 5
A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?
Correct Answer: D
Rationale: The correct answer is D. When a client has a peripherally inserted central catheter (PIC
C) in the right arm, blood pressure should not be taken on that side to avoid potential damage to the catheter or disrupting the infusion. It is crucial to protect the integrity and function of the PICC line by avoiding any procedures that could cause harm.
Choice A is incorrect because a right hemisphere stroke does not necessitate avoiding blood pressure measurements on the right arm.
Choice B is incorrect as using an arteriovenous shunt in the left lower forearm does not mandate avoiding blood pressure measurements on the right arm.
Choice C is incorrect because having blood drawn from the antecubital area does not impact blood pressure measurements on the contralateral arm.
In summary, the correct answer, D, is based on the need to protect the PICC line, while the other choices do not present a valid reason for avoiding blood pressure measurements on the right arm.
Question 4 of 5
A nurse is caring for a client who has a new prescription for spironolactone and reports that he forgot to tell the provider that he takes over-the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?
Correct Answer: B
Rationale: The correct answer is B: Potassium. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium. If the client takes potassium supplements along with spironolactone, it can lead to dangerously high levels of potassium in the blood (hyperkalemia), which can be life-threatening.
Therefore, the client should avoid taking additional potassium supplements while on spironolactone.
Incorrect options:
A: Calcium - Calcium supplements do not interact significantly with spironolactone.
C: Iron - Iron supplements do not interact significantly with spironolactone.
D: Magnesium - Magnesium supplements do not interact significantly with spironolactone.
Question 5 of 5
A nurse is teaching about leg and foot care to a client who has peripheral vascular disease of the lower extremities. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Use lamb's wool between toes that rub together. Lamb's wool helps prevent friction and skin breakdown between toes, which is important for clients with peripheral vascular disease to prevent ulcers. Wearing nylon socks (
A) can cause sweating and increase moisture, leading to skin irritation. Trimming toenails short and rounding the edges (
B) can increase the risk of ingrown toenails and cuts. Applying compression stockings that fit over the knees (
D) may not be suitable for clients with peripheral vascular disease as it can restrict blood flow.