ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Administer the mixture within 5 min of preparing it. This is important because regular insulin should always be drawn up before NPH insulin due to the risk of contaminating the regular insulin with NPH. Administering the mixture promptly ensures the insulin remains stable and effective.
Choice A is incorrect because shaking the vials can cause air bubbles and lead to inaccurate dosing.
Choice C is incorrect as NPH insulin should be drawn up after regular insulin to avoid contamination.
Choice D is incorrect as air should be injected into the vial after withdrawing insulin to prevent creating a vacuum.
Question 2 of 5
A nurse is reviewing a client’s laboratory results prior to administering medications. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C: SpO2 88%. This finding indicates low oxygen saturation levels, which can be life-threatening and require immediate medical attention. Oxygen saturation below 90% is considered critically low and can lead to hypoxemia. Reporting this to the provider promptly is crucial to ensure appropriate interventions are implemented to improve oxygenation.
A: Temperature within normal range.
B: Respiratory rate slightly elevated but not critical.
D: pH slightly low but not immediately life-threatening.
Question 3 of 5
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Position the client with her knees flexed and legs apart. This should be done first to provide proper access to the urethral meatus for catheter insertion. Flexing the knees and spreading the legs helps relax the pelvic muscles and facilitates the insertion process. Cleansing the meatus (choice
C) should be done after positioning the client. Lubricating the catheter (choice
A) comes after the meatus is cleansed. Attaching a prefilled syringe (choice
B) is the final step after the catheter is inserted.
Question 4 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 5 of 5
A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: Begin ball squeezing exercises. This helps prevent lymphedema by promoting lymphatic drainage. B: Avoid using the affected arm for eating is incorrect as it's important to gradually resume normal activities. C: Using deodorant under the affected arm can cause irritation or infection in the surgical site. D: Wearing a bra with wire support can cause discomfort and restrict lymphatic flow. It is vital to prioritize exercises that promote lymphatic drainage to prevent complications.