ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is performing an eye examination on a client. Which of the following findings should indicate to the nurse that the client might have cataracts?
Correct Answer: A
Rationale:
Correct Answer: A - A bluish-white colored pupil
Rationale: A bluish-white colored pupil can indicate the presence of cataracts, which cause clouding of the lens in the eye, leading to changes in pupil color. This finding is specific to cataracts.
Summary of Incorrect
Choices:
B: Decrease in peripheral vision - More indicative of conditions like glaucoma or retinal detachment.
C: Increased intraocular pressure - Suggestive of glaucoma, not cataracts.
D: Loss of central vision - Related to conditions like macular degeneration, not cataracts.
Question 2 of 5
A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?
Correct Answer: D
Rationale: The correct answer is D: Rotavirus. At 2 months, infants should receive the rotavirus vaccine to protect against severe diarrhea and dehydration. Rotavirus is a common cause of gastroenteritis in young children. Varicella (
A), Influenza (
B), and Hepatitis A (
C) vaccines are not typically given until the child is older. Providing a summary, Varicella, Influenza, and Hepatitis A vaccines are not recommended for a 2-month-old infant, making them incorrect choices.
Question 3 of 5
A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, 'I don't know what my surgery tomorrow is for.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct answer is B. The nurse should inform the provider that the client has questions about the surgery. This response is appropriate as it ensures the client's concerns are addressed by the healthcare provider who has the necessary expertise to provide detailed information about the upcoming procedure. It promotes effective communication between the client and the healthcare team, leading to a better understanding of the treatment plan.
Choice A is incorrect as simply noting the client's lack of understanding in the medical record does not address the client's immediate need for clarification.
Choice C is incorrect as it suggests discussing alternative treatment options, which may not be relevant if the surgery has already been scheduled.
Choice D is incorrect because the nurse should not provide detailed information about the procedure without involving the healthcare provider, who is responsible for explaining the specifics of the surgery to the client.
Question 4 of 5
A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?
Correct Answer: C
Rationale:
Rationale:
Choice C (Instruct the client to use an overbed trapeze to move around in bed) is correct because it promotes client independence and mobility without putting excessive pressure on the surgical site. This intervention helps prevent complications such as pressure ulcers and deep vein thrombosis. Turning the client every 4 hours (
Choice
A) may be too frequent and could disrupt wound healing. Placing the client on an air mattress (
Choice
B) may not be necessary and could potentially increase the risk of falls. Rewrapping the bandage every 8 hours in a circular pattern (
Choice
D) is incorrect as it can impede circulation and cause complications.
Extract:
Vital Signs
0830:
Temperature 35.1° C (95.2° F)
Heart rate 44/min
Respiratory rate 10/min
Blood pressure 84/45 mm Hg
Oxygen Saturation 90% on room air
Nurses' Notes
0800:
Client brought by ambulance to the ED with shallow breaths, slurred speech, confusion, and pupillary constriction. Minor abrasions noted on upper and lower extremities. Deep tendon reflexes (DTRs) 1+. Client vomited twice while in the care of emergency medical services. Family member fou the client lying on the sidewalk in front of the house. The client had not returned home last night, and the family member was going to see if the client's car was parked in the driveway.
Client's family member stated the client has had a change in their mood recently and was fired from their job for lack of attendance. The client came to live with the family member about 3 weeks ago after the client's partner divorced them, and they were without housing. The family member reports the client has been struggling for about a year with their back pain
Question 5 of 5
A nurse is caring for a client in the emergency department (ED).Exhibits: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale:
Correct Answer: B: Stimulant intoxication, Alcohol intoxication, Opioid withdrawal
Rationale:
- The client is most likely experiencing substance intoxication or withdrawal based on the ED setting and the need for nursing intervention.
- Actions: Address the specific condition by providing appropriate care and support, such as monitoring vital signs and providing symptom relief.
- Parameters to monitor: Respiratory rate and cardiac arrhythmias to assess the client's physiological response to the substance ingested.
Summary:
-
Choice A is incorrect because preparing for mechanical ventilation and administering clonidine are not appropriate initial interventions for substance intoxication or withdrawal.
-
Choice C is incorrect because pupillary reaction, hyperreflexia, and ethanol level are not specific enough to determine the client's condition or guide nursing interventions.
-
Choice D, E, F, G are not applicable or do not provide relevant information for the client's condition in the ED setting.