ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is reviewing a client’s laboratory results prior to administering medications. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C: SpO2 88%. This finding indicates low oxygen saturation levels, which can be life-threatening and require immediate medical attention. Oxygen saturation below 90% is considered critically low and can lead to hypoxemia. Reporting this to the provider promptly is crucial to ensure appropriate interventions are implemented to improve oxygenation.
A: Temperature within normal range.
B: Respiratory rate slightly elevated but not critical.
D: pH slightly low but not immediately life-threatening.
Question 2 of 5
A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?
Correct Answer: D
Rationale: The correct answer is D: Tighten a muscle group, then release the tension and move to the next one. This technique is known as progressive muscle relaxation, where the client systematically tenses and relaxes muscle groups to reduce physical tension and promote relaxation. By engaging in this process, the client becomes more aware of the physical sensations associated with stress and learns to release tension deliberately. This practice helps to bring about a state of deep relaxation and can be an effective tool in managing stress and anxiety.
Incorrect choices:
A: Picture taking the stress you feel and pushing it down and out of your feet - This choice involves visualization, not progressive relaxation.
B: Focus on a pleasant memory and express your emotions in writing - This choice focuses on emotional expression rather than physical tension release.
C: Think about a positive outcome to a stressful situation - This choice involves cognitive reframing, not muscle relaxation.
In summary, only choice D aligns with the technique of progressive muscle relaxation for stress management.
Question 3 of 5
A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?
Correct Answer: D
Rationale: The correct answer is D: Excessive sweating. Serotonin syndrome is a serious condition caused by excessive serotonin levels in the body. Excessive sweating is a key symptom of serotonin syndrome, indicating autonomic instability. This can lead to a potentially life-threatening situation if not promptly addressed. Dry mouth (
A), constipation (
B), and insomnia (
C) are common side effects of sertraline but are not indicative of serotonin syndrome. It is crucial to educate the client to monitor and report excessive sweating to prevent the progression of serotonin syndrome.
Question 4 of 5
A nurse is planning to administer packed RBCs to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: The correct answer is A: Infuse the transfusion over 5 hr. This is the correct action because older adults are more susceptible to adverse reactions during blood transfusions. Slow infusion over 5 hours reduces the risk of circulatory overload and other complications.
Choice B is incorrect because dextrose solution is not recommended for blood transfusions.
Choice C is incorrect as a larger gauge IV catheter, typically 18 or 19 gauge, is recommended for transfusing blood products.
Choice D is incorrect as vital signs should be monitored every 15 minutes for the first hour and then every 30 minutes for the remainder of the transfusion, not hourly.
Question 5 of 5
A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Turn on the faucets in the client's sink. This action helps stimulate the sound of running water, which can aid the client in urinating by triggering the relaxation of the bladder muscles through the auditory cue. Pouring cool water over the perineum (choice
A) may be uncomfortable and not necessarily effective in promoting urination. Instructing the client to stroke her lower abdomen (choice
C) may not directly address the issue of difficulty urinating. Instructing the client to lean slightly backward (choice
D) may not be helpful and could potentially cause discomfort.