ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will avoid crushing this medication." Metformin extended-release tablets should not be crushed, as it can alter the drug's release mechanism and potentially lead to an overdose. Crushing the medication can cause too much of the drug to be released at once, leading to adverse effects. Taking the medication in the morning (choice
A) or on an empty stomach (choice
B) are not necessarily incorrect but do not specifically demonstrate understanding of the teaching about avoiding crushing the tablets. Expecting to gain weight (choice
D) is unrelated to the administration of metformin.
Extract:
Vital Signs
0830:
Temperature 35.1° C (95.2° F)
Heart rate 44/min
Respiratory rate 10/min
Blood pressure 84/45 mm Hg
Oxygen Saturation 90% on room air
Nurses' Notes
0800:
Client brought by ambulance to the ED with shallow breaths, slurred speech, confusion, and pupillary constriction. Minor abrasions noted on upper and lower extremities. Deep tendon reflexes (DTRs) 1+. Client vomited twice while in the care of emergency medical services. Family member fou the client lying on the sidewalk in front of the house. The client had not returned home last night, and the family member was going to see if the client's car was parked in the driveway.
Client's family member stated the client has had a change in their mood recently and was fired from their job for lack of attendance. The client came to live with the family member about 3 weeks ago after the client's partner divorced them, and they were without housing. The family member reports the client has been struggling for about a year with their back pain
Question 2 of 5
A nurse is caring for a client in the emergency department (ED).Exhibits: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale:
Correct Answer: B: Stimulant intoxication, Alcohol intoxication, Opioid withdrawal
Rationale:
- The client is most likely experiencing substance intoxication or withdrawal based on the ED setting and the need for nursing intervention.
- Actions: Address the specific condition by providing appropriate care and support, such as monitoring vital signs and providing symptom relief.
- Parameters to monitor: Respiratory rate and cardiac arrhythmias to assess the client's physiological response to the substance ingested.
Summary:
-
Choice A is incorrect because preparing for mechanical ventilation and administering clonidine are not appropriate initial interventions for substance intoxication or withdrawal.
-
Choice C is incorrect because pupillary reaction, hyperreflexia, and ethanol level are not specific enough to determine the client's condition or guide nursing interventions.
-
Choice D, E, F, G are not applicable or do not provide relevant information for the client's condition in the ED setting.
Extract:
Question 3 of 5
A nurse is caring for a client who is experiencing acute alcohol toxicity. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale: The correct answer is C: Measure the client's urine specific gravity. This is important to monitor hydration status and kidney function in a client with acute alcohol toxicity. High specific gravity indicates dehydration, while low specific gravity may indicate overhydration or impaired kidney function. Administering a stimulant (
A) can worsen the client's condition by increasing heart rate and blood pressure. Administering a diuretic (
B) may further dehydrate the client. Inserting an NG tube (
D) is not indicated unless the client is at risk for aspiration.
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:
Correct Answer: A,B,D
Rationale:
A. Initiate an IV infusion of lactated Ringer's: Anticipated because IV fluids help maintain hydration and electrolyte balance, crucial for the pregnant client.
B. Place the client in a left lateral position: Anticipated as this position improves blood flow to the placenta and reduces pressure on the vena cava, enhancing fetal oxygenation.
C. Monitor blood pressure every hour: Not contraindicated, but it is not explicitly stated in the question that it is needed, so it is not the best choice compared to the other options.
D. Maintain continuous monitoring of the FHR: Anticipated as it provides vital information about fetal well-being and helps detect any potential issues promptly.
Extract:
Question 5 of 5
A nurse is teaching a client who has major depressive disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client?
Correct Answer: C
Rationale: The correct answer is C: You might feel a bit confused for a few hours after the procedure. This is because confusion is a common side effect of electroconvulsive therapy (ECT) due to the temporary disruption of cognitive functions. The confusion typically resolves within a few hours post-procedure.
Choice A is incorrect because feeling pulsations in the neck is not a typical sensation experienced during ECT.
Choice B is incorrect as the client usually wakes up shortly after the procedure, not 30 minutes later.
Choice D is incorrect as changes in voice are not a common side effect of ECT.