ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A. Acute epiglottitis is a medical emergency that can lead to airway obstruction. The nurse should assess this child first to ensure airway patency. Drooling is a sign of difficulty swallowing and impending airway compromise. The nurse should act promptly to prevent respiratory distress.
Choices B, C, and D do not present immediate life-threatening conditions that require urgent assessment. Bright red blood in urine in a child with a UTI may indicate a more severe infection, but it does not require immediate intervention like airway management. Severe fatigue in a child with mononucleosis and an abdominal mass in a child with Wilms' tumor are concerning, but they do not pose immediate threats to the child's airway.
Question 2 of 5
A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day. Which of the following actions should the nurse include in the plan?
Correct Answer: B
Rationale: The correct answer is B: Use container lids of different shapes to indicate times of administration. This option promotes medication adherence for the client with vision loss by providing a tactile cue for different medication times. Rearranging furniture (
A) does not directly address medication management. Covering appliance cords with throw rugs (
C) poses a safety hazard. Visiting the client once per month (
D) is not frequent enough for proper medication monitoring.
Question 3 of 5
A nurse is planning to administer packed RBCs to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: The correct answer is A: Infuse the transfusion over 5 hr. This is the correct action because older adults are more susceptible to adverse reactions during blood transfusions. Slow infusion over 5 hours reduces the risk of circulatory overload and other complications.
Choice B is incorrect because dextrose solution is not recommended for blood transfusions.
Choice C is incorrect as a larger gauge IV catheter, typically 18 or 19 gauge, is recommended for transfusing blood products.
Choice D is incorrect as vital signs should be monitored every 15 minutes for the first hour and then every 30 minutes for the remainder of the transfusion, not hourly.
Question 4 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 5 of 5
A nurse is reviewing the laboratory results of a client who has hypothyroidism. The client's calcium level is 7.6 mg/dL. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Muscle twitching. In hypothyroidism, low thyroid hormone levels can lead to hypocalcemia, causing muscle twitching due to increased neuromuscular excitability. B: Hypertension is not typically associated with hypothyroidism. C: Bounding pulse is more indicative of hyperthyroidism. D: Hypoactive bowel sounds are not directly related to hypothyroidism.