ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 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 2 of 5
A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Heart rate 148/min. A heart rate of 148/min in a 3-year-old toddler with dehydration indicates tachycardia, which is a significant finding that should be reported to the provider. Tachycardia is a compensatory mechanism in response to dehydration to maintain cardiac output. It can indicate hypovolemia and the need for further intervention. The other choices (B: Potassium 3.9 mEq/L, C: Respiratory rate 22/min, D: Sodium 142 mEq/L) are within normal limits for a 3-year-old and do not directly indicate dehydration or immediate concern. Reporting a high heart rate is crucial for timely intervention in managing the toddler's dehydration.
Question 3 of 5
A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?
Correct Answer: D
Rationale: The correct answer is D because washing hands with alcohol-based hand rub after bathing a client with Clostridium difficile is not sufficient to remove spores. Handwashing with soap and water is necessary to effectively remove C. difficile spores.
Choice A is correct because wearing clean gloves is appropriate when emptying a urinary catheter bag.
Choice B is correct because performing a simple dressing change is within the scope of practice for an AP.
Choice C is correct because providing postmortem care is a necessary task after a client's death.
Question 4 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 5 of 5
A nurse is reviewing laboratory data for a client who has a new prescription for valproic acid. Which of the following baseline results should the nurse review prior to administering the first dose of the medication?
Correct Answer: D
Rationale: The correct answer is D: Liver function tests. Valproic acid is known to potentially cause liver toxicity.
Therefore, reviewing liver function tests before administering the medication is crucial to assess the baseline liver function and monitor for any potential adverse effects.
A: Potassium level - not directly related to valproic acid administration.
B: Thyroid function tests - not necessary for assessing the safety of starting valproic acid.
C: Uric acid level - not directly related to valproic acid administration.