ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?
Correct Answer: B
Rationale: The correct answer is B: Padded clamp. This equipment is necessary for managing the chest tube, which helps drain air or fluid from the pleural space after a thoracotomy. The padded clamp is used to temporarily occlude the tube during dressing changes or when the system needs to be disconnected. Wire cutters (
A) are not typically needed for chest tube care. Montgomery straps (
C) are used for securing dressings, not for chest tube management. Tracheostomy tray (
D) is unrelated to thoracotomy care.
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
In which order should the nurse perform the following steps for administering timolol eye drops? A. Administer the prescribed number of drops, B. Apply gentle pressure to the client's punctum, C. Tilt the client's head backward toward the ceiling, D. Pull the client's lower lid down with the nondominant hand, E. Verify the clarity and color of the eye drops.
Correct Answer: E,C,D,A,B
Rationale: The correct order for administering timolol eye drops is as follows:
E. Verify the clarity and color of the eye drops - This step ensures the correct medication is being used.
C. Tilt the client's head backward toward the ceiling - This position helps the drops enter the eye properly.
D. Pull the client's lower lid down with the nondominant hand - This helps create a pocket for the drops.
A. Administer the prescribed number of drops - The actual administration of the medication.
B. Apply gentle pressure to the client's punctum - This helps prevent systemic absorption of the medication.
The other choices are incorrect because they are not in the correct sequence for administering eye drops effectively.
Question 4 of 5
A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Encourage the child to play with toys such as a pounding board. This is appropriate because play is an essential component of a preschooler's development and can help reduce anxiety during their stay. Providing toys like a pounding board can promote fine motor skills and distract the child from the unfamiliar hospital environment.
Establishing a new routine (choice
A) may cause more stress for the child as they are already in an unfamiliar setting. Using medical terminology (choice
B) can be confusing and intimidating for a preschooler. Performing assessments when the parent is not in the room (choice
D) may not be ideal as the child may feel more comfortable and reassured with their parent present.
Question 5 of 5
A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?
Correct Answer: B
Rationale: The correct answer is B: A child who has bacterial meningitis. Seizure precautions should be initiated for this client due to the risk of seizures associated with meningitis. Bacterial meningitis can lead to increased intracranial pressure, inflammation of the brain, and potential neurological complications, all of which can trigger seizures. Seizure precautions are necessary to prevent injury during a seizure episode.
Incorrect options:
A: An infant with respiratory syncytial virus does not typically require seizure precautions as RSV primarily affects the respiratory system.
C: An infant with hypertrophic pyloric stenosis may not be at immediate risk of seizures unless there are complications.
D: A child with Kawasaki disease typically does not present with seizures as a primary symptom.