ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 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 2 of 5
A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following adverse effects of the medication is the priority finding for the nurse to report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Irregular pulse. This is the priority finding to report because it could indicate a potentially serious cardiac side effect of risperidone. Irregular pulse can lead to serious complications like arrhythmias or cardiac arrest. Constipation (
A), visual disturbances (
B), and dry mouth (
C) are common side effects of risperidone but are not typically life-threatening or urgent. Reporting irregular pulse promptly allows for timely intervention to prevent serious cardiac events.
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 3 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 4 of 5
A nurse is teaching a client who has a new prescription for tetracycline. Which of the following information should the nurse include in the teaching?
Correct Answer: D
Rationale: The correct answer is D: Light sensitivity is an adverse effect of this medication. Tetracycline can cause photosensitivity, making the skin more sensitive to sunlight and increasing the risk of sunburn or skin damage. This information is crucial for the client to prevent potential harm.
A: Taking tetracycline with milk can decrease its absorption, so it should be avoided.
B: There is no specific instruction to take tetracycline at bedtime.
C: Constipation is not a common adverse effect of tetracycline.
In summary, choice D is correct because it addresses a significant adverse effect of the medication, while the other choices are either incorrect or irrelevant to tetracycline therapy.
Question 5 of 5
A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: D
Rationale: The correct answer is D: Instruct visitors to stay 1 m (3.3 feet) away from the client. This is important in brachytherapy to minimize radiation exposure to others. Keeping a safe distance helps reduce the risk of radiation exposure. Straining the client's urine (
A) is not necessary for brachytherapy. Limiting visitors' time (
B) does not directly relate to radiation safety. Attaching a dosimeter (
C) is not typically done with low-dose radiation implants.
Therefore, the best choice is D to ensure visitor safety.