ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action to take first when inserting an indwelling urinary catheter is to position the sterile drape leaving the perineum exposed (choice
D). This step is crucial to maintain a sterile field and prevent contamination during the procedure. By positioning the sterile drape first, the nurse ensures that the area where the catheter will be inserted remains clean and free from pathogens.
Lubricating the catheter with water-soluble gel (choice
A) is an important step in the procedure, but it should be done after the sterile field is established. Attaching a prefilled syringe to the catheter inflation hub (choice
B) is not the first step as it pertains to securing the catheter in place after insertion. Cleansing the client's meatus with antiseptic solution (choice
C) is also an essential step but should be performed after positioning the sterile drape.
Question 2 of 5
A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?
Correct Answer: D
Rationale: The correct answer is D: Rotavirus. At 2 months, infants should receive the rotavirus vaccine to protect against severe diarrhea and dehydration. Rotavirus is a common cause of gastroenteritis in young children. Varicella (
A), Influenza (
B), and Hepatitis A (
C) vaccines are not typically given until the child is older. Providing a summary, Varicella, Influenza, and Hepatitis A vaccines are not recommended for a 2-month-old infant, making them incorrect choices.
Question 3 of 5
A nurse observes two assistive personnel (AP) discussing a client's information in the facility cafeteria. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Remind the AP about maintaining client confidentiality. The nurse should address the issue directly with the AP to reinforce the importance of maintaining client confidentiality. This action helps educate the AP on proper conduct and ensures compliance with privacy regulations.
Choices B, C, and D are incorrect because they do not address the immediate issue at hand and may escalate the situation unnecessarily. Notifying the client could breach confidentiality further, involving the ethics committee may be premature, and filing an incident report without addressing the behavior directly may not prevent future violations.
Question 4 of 5
A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Small clots with tissue in the urine. After a transurethral resection of the prostate, it is common to see small clots with tissue in the urine due to the trauma caused by the procedure. This finding is expected as the body heals postoperatively.
Incorrect Answers:
B: Dark red urine would indicate active bleeding, which is not a normal finding in this situation.
C: Urinary output of 25 mL/hr is below the normal range and may indicate inadequate hydration or potential kidney issues, not a typical finding postoperatively.
D: Pain of 8 on a scale of 0 to 10 is a high level of pain and should be addressed promptly, but it is not a typical finding associated with this specific postoperative period.
Question 5 of 5
A nurse is caring for a client who is scheduled to undergo a procedure the following day. The client states, 'I don't know what my surgery tomorrow is for.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct answer is B. The nurse should inform the provider that the client has questions about the surgery. This response is appropriate as it ensures the client's concerns are addressed by the healthcare provider who has the necessary expertise to provide detailed information about the upcoming procedure. It promotes effective communication between the client and the healthcare team, leading to a better understanding of the treatment plan.
Choice A is incorrect as simply noting the client's lack of understanding in the medical record does not address the client's immediate need for clarification.
Choice C is incorrect as it suggests discussing alternative treatment options, which may not be relevant if the surgery has already been scheduled.
Choice D is incorrect because the nurse should not provide detailed information about the procedure without involving the healthcare provider, who is responsible for explaining the specifics of the surgery to the client.