ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is planning care for a client prior to an amniocentesis. Which of the fetal heart rate throughout the procedure?
Correct Answer: D
Rationale: The correct answer is D: Monitor the fetal heart rate throughout the procedure. This is essential to ensure the safety and well-being of the fetus during the invasive procedure, allowing for prompt detection of any distress or changes in heart rate. Placing the client in Trendelenburg position (
A) is unnecessary and may even be harmful. Instructing the client to maintain a full bladder (
B) is not relevant to monitoring the fetal heart rate. Administering a tocolytic (
C) is not indicated as it is used to stop preterm labor contractions, not for monitoring fetal heart rate. Monitoring the fetal heart rate (
D) is crucial in assessing fetal well-being and detecting any signs of distress promptly.
Question 2 of 5
A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C: Scrambled eggs. This food choice is appropriate for a client with dysphagia caused by a stroke because it is soft and easy to swallow, reducing the risk of aspiration. Scrambled eggs are also a good source of protein and nutrients.
A: Crispy rice bar is not recommended as it is hard and can pose a choking hazard for someone with dysphagia.
B: Soda crackers are dry and can be difficult to swallow without enough liquid, increasing the risk of choking.
D: Peanut butter is thick and sticky, making it challenging for someone with dysphagia to swallow safely.
In summary, scrambled eggs are the best choice due to their soft texture and nutritional value, while the other options pose potential risks for individuals with dysphagia.
Question 3 of 5
A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is important to maintain the water seal, which prevents air from entering the pleural space. If the water level is too low, the system may not function properly. Emptying the collection chamber every 8 hr (choice
A) is incorrect because it depends on the amount of drainage, not a fixed time frame. Checking the patency of the tubing every 2 hr (choice
B) is unnecessary and may introduce unnecessary contamination. Keeping the drainage system above the level of the client's chest (choice
C) is incorrect as it may cause backflow of drainage.
Question 4 of 5
A client on an acute mental health unit states to a nurse, 'Tie a bow. Row the boat. Now I know. Whoa! I see you, yo.' The nurse should document that the client is exhibiting which of the following speech alterations?
Correct Answer: C
Rationale: The correct answer is C: Clang association. Clang association refers to a speech pattern where words are chosen based on their sound rather than their meaning. In this case, the client's speech is characterized by rhyming and alliteration, such as "bow" and "row," indicating a connection based on sound rather than coherent meaning. Echolalia (
A) is the repetition of words spoken by others, which is not present here. Word salad (
B) is a jumble of unrelated words and phrases that do not make sense. Neologisms (
D) are made-up words, which are also not present in the client's speech.
Therefore, Clang association best describes the speech alteration exhibited by the client in this scenario.
Question 5 of 5
A nurse is teaching a class of newly licensed nurses about infectious diseases that nurses are required to report to the health department. Which of the following diseases should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Pulmonary tuberculosis. Tuberculosis is a highly contagious infectious disease that is required to be reported to the health department due to its potential for rapid spread in the community. Reporting helps in controlling the spread of the disease and initiating timely treatment for affected individuals. Methicillin-resistant Staphylococcus aureus (
A) is an antibiotic-resistant bacterium that may not require mandatory reporting. Herpes simplex virus (
C) is a common viral infection that is not typically reportable to the health department. Fibromyalgia syndrome (
D) is a chronic pain condition and not an infectious disease that requires reporting.