ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?
Correct Answer: B
Rationale: The correct answer is B because informing the oncoming nurse about a recent lung biopsy is crucial for continuity of care and monitoring for any complications. This information is time-sensitive and could impact the client's immediate care needs.
Choices A, C, and D are not as critical for immediate care planning during shift change. A recent administration of morphine may be important, but not as urgent as a recent procedure like a lung biopsy. Vital signs being obtained every 4 hours is routine and not specific to the current situation. The presence of the client's partner, while important for emotional support, is not a critical detail for immediate care planning during shift change.
Question 2 of 5
A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like 'something opened up.' The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take in this scenario is to cover the wound with a saline-soaked dressing (
Choice
C). This is based on the principle of protecting the exposed tissue from contamination and preventing further complications such as infection. By covering the wound with a saline-soaked dressing, the nurse can create a moist environment that can help promote healing and reduce the risk of infection. Reinserting the protruding intestinal tissue (
Choice
A) should not be done by the nurse, as this is a medical intervention that should be performed by a healthcare provider. Placing the client in Trendelenburg position (
Choice
B) is not necessary and may not address the primary concern of wound separation. Monitoring vital signs every 30 minutes (
Choice
D) is important but not the immediate priority when there is protrusion of intestinal tissue.
Question 3 of 5
A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: White fish. White fish is a low-fat protein source that is gentle on the stomach and less likely to trigger acid reflux compared to other protein sources like red meat. It is also less acidic, making it a suitable choice for someone with GERD. Decaffeinated coffee (
A) can still trigger acid reflux due to its acidity.
Tomato soup (
B) is high in acidity and may exacerbate GERD symptoms. Hot cocoa (
D) is also acidic and can worsen GERD. In summary, white fish is the best option for someone with GERD due to its low fat and low acidity content.
Question 4 of 5
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Nervousness. A blood glucose level of 64 mg/dL indicates hypoglycemia in a client with type 1 diabetes. Nervousness is a common symptom of hypoglycemia due to the body's stress response to low blood sugar. Tachypnea (choice
A) is more likely to be seen in diabetic ketoacidosis. Ketonuria (choice
B) is a sign of hyperglycemia and ketosis, not hypoglycemia. Warm skin (choice
C) is not specific to any particular blood glucose level.
Therefore, the nurse should expect the client to display nervousness as a result of the low blood glucose level.
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 5 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 .