ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Select a site proximal to previous venipuncture sites. This is important to prevent complications like phlebitis and infiltration. Choosing the client's dominant arm (
A) may not always be necessary. Initiating IV access on the palmar side of the wrist (
C) is not ideal due to the risk of nerve damage. Inserting a larger gauge IV catheter (
D) can increase the risk of phlebitis and should be avoided unless necessary.
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
2100:
Temperature 37.5° C (99.5° F)
Heart rate 104/min
Respiratory rate 20/min
Blood pressure 132/84 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:
Contractions occurring every 4 to 5 min, lasting 40 to 60
seconds. Small amount of bloody show noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0 to 10, breathing well through contractions. FHR 168/min, minimal variability. Client denies epigastric pain or
Question 2 of 5
A nurse in an antepartum unit is caring for a client. Which of the following actions should the nurse take?
Correct Answer: A,C,D,F,G
Rationale: The correct actions for the nurse to take are A, C, D, F, and G. Administering oxygen at 10L/min via a nonrebreather face mask is important for respiratory support. Initiating a bolus of IV fluid helps maintain adequate hydration and perfusion. Assisting the client to the left lateral position promotes optimal blood flow to the fetus. Notifying the provider of the client's condition ensures timely intervention. Lastly, preparing to administer an amnioinfusion may be necessary based on the client's condition. These actions prioritize the client's respiratory, circulatory, and fetal well-being. Other choices like requesting hydralazine or oxytocin may not be indicated without proper assessment and prescription.
Extract:
Question 3 of 5
A nurse is assessing an older adult client. Which of the following statements indicates that the client is at a risk for being socially isolated?
Correct Answer: C
Rationale: The correct answer is C. The statement indicates a risk for social isolation because the client is unable to attend church due to a lost hearing aid. This can lead to reduced social interactions and feelings of loneliness.
Choice A does not necessarily indicate social isolation, just potential hearing loss.
Choice B still involves some social interaction.
Choice D shows some social support.
Question 4 of 5
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Select a site proximal to previous venipuncture sites. This is important to prevent complications like phlebitis and infiltration. Choosing the client's dominant arm (
A) may not always be necessary. Initiating IV access on the palmar side of the wrist (
C) is not ideal due to the risk of nerve damage. Inserting a larger gauge IV catheter (
D) can increase the risk of phlebitis and should be avoided unless necessary.
Question 5 of 5
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Correct Answer: D
Rationale: The correct answer is D: Frequent swallowing. This is the priority finding as it could indicate bleeding after tonsillectomy, which is a potential complication requiring immediate attention. Dark brown emesis (choice
B) could also indicate bleeding but is less specific. Sore throat (choice
A) is expected post-operatively. Blood-tinged mucus (choice
C) can be common after tonsillectomy.
Therefore, the priority is to assess for signs of bleeding, which is most indicative by frequent swallowing.