ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Instruct the client to bear down when the speculum is inserted. This action helps to relax the pelvic floor muscles, making it easier to insert the speculum. Holding the breath (
A) can increase tension and discomfort. Ensuring a full bladder (
B) is not necessary and can actually be uncomfortable. Placing the client in modified Sims' position (
D) is used for rectal examinations, not pelvic exams.
Extract:
Admission Assessments: Client admitted to labor and delivery. Gravida 1, para 0 at 40 weeks of gestation, presents with contractions every 5 to 6 min, 30 to 40 seconds duration, 2+ intensity. Client reports their water broke and the fluid was clear. Positive for group B Streptococcus B-hemolytic at 37 weeks. Sterile vaginal examination. Cervix 5 cm dilated, 50% effaced, and 0 station. Flow Sheet: 1130:
Fetal heart rate 140/min with moderate variability. Intermittent accelerations. Contractions moderate, average 80 seconds duration.
1210:
Fetal heart rate 140/min with moderate variability. Early deceleration. Contractions moderate, average 90 seconds duration.
1215:
Fetal heart rate 120/min with minimal variability Early decelerations. Vital Sign:1130:
Temperature 36.4° C (97.5° F)
Heart rate 84/min
Respiratory rate 18/min
BP 124/82 mm Hg
1200:
Temperature 36.5° C (97.7° F)
Heart rate 90/min.
Respiratory rate 18/min
BP 128/84 mm Hg
1215:
Temperature 37.1° C (98.8° F)
Heart rate 86/min
Respiratory rate 18/min
BP 120/80 mm Hg
Question 2 of 5
The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client: A. Decrease the IV flow rate, B. Monitor fetal heart rate, C. Administer ampicillin IV, D. Place client in left lateral position, E. Request a prescription for ephedrine.
| Options | Essential | Contrainidication |
|---|---|---|
| Decrease the IV flow rate | ||
| Monitor fetal heart rate | ||
| Administer ampicillin IV | ||
| Place client in left lateral position | ||
| Request a prescription for ephedrine |
Correct Answer:
Rationale:
To determine the correct answer, we must consider the implications of an epidural insertion. Decreasing the IV flow rate is essential to prevent hypotension which can occur due to the epidural anesthesia. Monitoring fetal heart rate is essential to ensure fetal well-being. Administering ampicillin IV and requesting ephedrine are not directly related to the client's condition post-epidural, so they are contraindicated. Placing the client in the left lateral position helps to optimize blood flow to the placenta and is essential post-epidural.
Therefore, the correct answer is .
Extract:
Question 3 of 5
A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?
Correct Answer: D
Rationale: The correct answer is D: Secure the catheter to the client's thigh. Securing the catheter to the client's thigh helps prevent tension on the catheter, reducing the risk of trauma to the urinary tract mucosa that can lead to UTIs. Placing the urinary bag at bladder level (choice
A) when ambulating does not directly minimize the risk of UTI. Looping the tubing lower than the collection bag (choice
B) can lead to backflow of urine, increasing the risk of infection. Obtaining urinary samples by disconnecting tubing connections (choice
C) poses a risk of contamination. Option D is the best choice for minimizing UTI risk.
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
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, O 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.
Question 4 of 5
A nurse in an antepartum unit is caring for a client.Exhibits Select the 2 findings that require immediate follow-up.
Correct Answer: B,D
Rationale: The correct answers are B (Fetal heart rate) and D (Characteristics of amniotic fluid) because these findings are critical indicators of fetal well-being. Changes in fetal heart rate may indicate fetal distress, requiring immediate intervention. Monitoring amniotic fluid characteristics is crucial to assess for potential complications like infection or rupture. Blood pressure, fetal station, and contraction duration are important but not as urgent as fetal heart rate and amniotic fluid assessment in this context.
Extract:
Question 5 of 5
A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's temperature every 4 hr. Neutropenia puts the client at high risk for infection due to low neutrophil count. Monitoring temperature helps detect early signs of infection.
Choice A is incorrect as sterile technique is required to prevent infection.
Choice B is incorrect as healthy visitors can introduce infections.
Choice C is incorrect as frequent room cleaning can disrupt the client's protective environment.