ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is preparing to administer medication to a client and discovers that a nurse on the previous shift gave the client an incorrect dose of the medication. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: Forwarding a completed incident report to the risk manager within 24 hours is the correct action for the nurse to take in this scenario. This is important to ensure that the medication error is documented and investigated promptly to prevent harm to the client and to identify any system issues that led to the error. It also follows proper protocol for reporting and addressing medication errors in healthcare settings.
Summary of other choices:
B: Notifying the facility's pharmacist within 1 hour may be important for immediate safety concerns, but the incident report should still be completed and forwarded to the risk manager.
C: Calling the nurse who made the error may be appropriate for clarifying details but should not replace the formal incident reporting process.
D: Placing an incident report in the client's medical record is necessary, but it should also be forwarded to the risk manager for further investigation and action.
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
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.
Extract:
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.
Question 4 of 5
A nurse in an antepartum unit is caring for a client., For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia: A. Purulent amniotic fluid, B. Elevated uric acid level, C. Fever, D. Decreased platelet count, E. Blurred vision.
Correct Answer: A,C,B,D,E
Rationale: The correct answer is A, C, B, D, E.
A. Purulent amniotic fluid is consistent with chorioamnionitis, an infection of the amniotic fluid and membranes.
C. Fever is a common sign of both chorioamnionitis and preeclampsia but is more specific to chorioamnionitis.
B. Elevated uric acid level is more indicative of preeclampsia due to impaired kidney function.
D. Decreased platelet count is a sign of preeclampsia, indicating potential liver dysfunction.
E. Blurred vision is a hallmark sign of severe preeclampsia due to elevated blood pressure affecting the retina.
Therefore, the correct answer includes findings that are specific to both chorioamnionitis and preeclampsia, providing a comprehensive assessment approach.
Extract:
Question 5 of 5
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Correct Answer: D
Rationale: The correct answer is D: Frequent swallowing. This is the priority finding as it could indicate bleeding after tonsillectomy, which is a potential complication requiring immediate attention. Dark brown emesis (choice
B) could also indicate bleeding but is less specific. Sore throat (choice
A) is expected post-operatively. Blood-tinged mucus (choice
C) can be common after tonsillectomy.
Therefore, the priority is to assess for signs of bleeding, which is most indicative by frequent swallowing.