ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is preparing to administer naloxone IV bolus to a client who has opioid use disorder and has developed acute opioid toxicity. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min. This is crucial because naloxone can cause rapid reversal of opioid effects, leading to potential adverse reactions such as hypertension, tachycardia, and pulmonary edema. Monitoring vital signs frequently allows the nurse to promptly identify and manage these complications.
Choice B is incorrect because giving naloxone slowly for 15 seconds may delay the onset of action and compromise the client's safety in cases of opioid toxicity.
Choice C is incorrect as the onset of naloxone typically occurs within minutes, not 15 minutes.
Choice D is incorrect as the effects of naloxone are short-acting and do not last for 24 hours.
Question 2 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 3 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: C
Rationale: The correct answer is C because monitoring the client's temperature every 4 hours is crucial for early detection of infection in neutropenic patients, as they have compromised immune systems. This allows for timely intervention and prevention of complications.
Choice A is incorrect as sterile technique is necessary for invasive procedures to prevent infection.
Choice B is incorrect as exposing neutropenic patients to healthy individuals increases their risk of infection.
Choice D is incorrect as frequent cleaning of the client's room is essential to minimize exposure to pathogens.
Question 4 of 5
A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding her newborn. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale:
Correct Answer: A: You should wear a snug-fitting bra continuously for 72 hours.
Rationale: Wearing a snug-fitting bra provides support and pressure on the breasts, which helps to suppress lactation. This continuous pressure helps to decrease milk production by limiting the milk ducts' ability to refill. By wearing the bra for 72 hours, the client can effectively suppress lactation.
Summary of other choices:
B: Applying moist heat to the breasts can actually stimulate milk production rather than suppress it.
C: Limiting fluid intake to 1 liter per day is not recommended as it can lead to dehydration and does not directly impact lactation suppression.
D: Manually expressing milk when engorgement occurs can stimulate further milk production, which goes against the goal of lactation suppression.
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.