ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A school nurse is using Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?
Correct Answer: B
Rationale:
Correct Answer: B. Place a vibrating tuning fork on the top of the child's head.
Rationale: In Weber's test, the tuning fork is placed on the midline of the patient's head. If the sound is heard equally in both ears, the hearing is considered normal. If the sound is louder in one ear, it indicates a conductive or sensorineural hearing loss.
Summary:
A: Incorrect. Placing the vibrating tuning fork close to the ears may not provide an accurate assessment of hearing acuity.
C: Incorrect. Whispering a statement to the child does not involve the use of a tuning fork for Weber's test.
D: Incorrect. Headphones are not used in Weber's test; it requires a tuning fork placed on the head.
E, F, G: No information provided.
Question 2 of 5
A nurse is teaching about safe handling of formula to a client who is postpartum and chooses to bottle feed her newborn. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I should boil tap water for 2 minutes and cool it before I mix it with the powdered formula." This statement indicates an understanding of safe formula handling. Boiling tap water for 2 minutes helps to sterilize it, reducing the risk of bacterial contamination when mixing with powdered formula. This is crucial for the baby's health.
Incorrect choices:
A: Bottles should not contain BPA as it can be harmful to the baby.
B: Keeping concentrated formula in the refrigerator for 3 days after opening can lead to bacterial growth.
D: Diluting ready-to-feed formula with water can disrupt the balance of nutrients and hydration levels, potentially harming the baby.
Question 3 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 answer is C: Cover the wound with a saline-soaked dressing. This action is appropriate because it helps to prevent further damage to the exposed intestinal tissue and maintains a moist environment to promote healing. Placing the client in Trendelenburg position (
A) is not recommended as it can increase intra-abdominal pressure and worsen the situation. Reinserting the protruding intestinal tissue (
B) should not be done by the nurse as it can lead to complications and is beyond the scope of nursing practice. Monitoring vital signs every 30 minutes (
D) is important but not the immediate priority in this situation where wound coverage is crucial.
Question 4 of 5
A nurse is teaching a client how to care for his behind-the-ear hearing aids. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I'll disconnect the battery when I remove my hearing aids." This statement indicates an understanding of proper care because disconnecting the battery helps conserve battery life and prevents corrosion. Isopropyl alcohol (choice
A) is not recommended as it can damage the hearing aid. Replacing batteries every 2 weeks (choice
B) is a general guideline and may not be necessary if the batteries are still functioning. Cleaning the ear with cotton swabs (choice
D) can push wax further into the ear canal, potentially damaging the hearing aid.
Question 5 of 5
A nurse is planning care for a client who is undergoing alcohol withdrawal and is receiving diazepam. Which of the following interventions should the nurse include in the plan?
Correct Answer: B
Rationale: The correct answer is B: Initiate seizure precautions. Diazepam is a benzodiazepine commonly used to manage alcohol withdrawal symptoms, including seizures. Seizure precautions involve monitoring the client's environment for safety, such as padding the bed rails and ensuring a clear space around the client. This intervention is crucial as alcohol withdrawal can lead to life-threatening seizures. Administering the medication subcutaneously (
A) is not typically recommended for diazepam as it is usually given orally or intravenously. Administering the medication with an antacid (
C) is not necessary for diazepam. Initiating contact precautions (
D) is not relevant in this situation as alcohol withdrawal does not require isolation precautions.