ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?
Correct Answer: A
Rationale: A child with cystic fibrosis and difficulty clearing secretions is the priority due to airway clearance needs. Heart rate of 120/min, blood sugar of 150 mg/dL, and diarrhea are less urgent.
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: Administer oxygen, initiate IV fluid bolus, assist to left lateral position, notify the provider, and prepare for amnioinfusion address fetal distress indicated by tachycardia and meconium-stained fluid. Hydralazine is not needed for normal BP, and oxytocin may worsen distress.
Extract:
Question 3 of 5
A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate?
Correct Answer: B
Rationale: Droplet. Bacterial meningitis is transmitted through respiratory secretions, requiring droplet precautions. Protective environments are for immunocompromised clients, and contact or airborne precautions are not appropriate.
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
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:
Question 4 of 5
A nurse in an antepartum unit is caring for a client. For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client: A. Initiate an IV infusion of lactated Ringer's, B. Place the client in a left lateral position, C. Monitor blood pressure every hour, D. Maintain continuous monitoring of the FHR.
Correct Answer: A,B,D
Rationale: Initiate an IV infusion of lactated Ringer’s, place the client in a left lateral position, and maintain continuous FHR monitoring are anticipated to support hydration, perfusion, and fetal monitoring. Monitoring blood pressure every hour is contraindicated; more frequent monitoring is needed due to hypertension and gestational diabetes risks.
Extract:
Question 5 of 5
A nurse is assessing an older adult client. Which of the following statements indicates that the client is at a risk for being socially isolated?
Correct Answer: C
Rationale: Not attending church due to a lost hearing aid suggests withdrawal from social activities, increasing isolation risk. Loud speech, limited babysitting, or grocery trips do not indicate isolation.