ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Admission Assessments: Client admitted to labor and delivery. Gravida 1, para 0 at 40 weeks of gestation, presents with contractions every 5 to 6 min, 30 to 40 seconds duration, 2+ intensity. Client reports their water broke and the fluid was clear. Positive for group B Streptococcus B-hemolytic at 37 weeks. Sterile vaginal examination. Cervix 5 cm dilated, 50% effaced, and 0 station. Flow Sheet: 1130:
Fetal heart rate 140/min with moderate variability. Intermittent accelerations. Contractions moderate, average 80 seconds duration.
1210:
Fetal heart rate 140/min with moderate variability. Early deceleration. Contractions moderate, average 90 seconds duration.
1215:
Fetal heart rate 120/min with minimal variability Early decelerations. Vital Sign:1130:
Temperature 36.4° C (97.5° F)
Heart rate 84/min
Respiratory rate 18/min
BP 124/82 mm Hg
1200:
Temperature 36.5° C (97.7° F)
Heart rate 90/min.
Respiratory rate 18/min
BP 128/84 mm Hg
1215:
Temperature 37.1° C (98.8° F)
Heart rate 86/min
Respiratory rate 18/min
BP 120/80 mm Hg
Question 1 of 5
The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client: A. Decrease the IV flow rate, B. Monitor fetal heart rate, C. Administer ampicillin IV, D. Place client in left lateral position, E. Request a prescription for ephedrine.
| Options | Essential | Contrainidication |
|---|---|---|
| Decrease the IV flow rate | ||
| Monitor fetal heart rate | ||
| Administer ampicillin IV | ||
| Place client in left lateral position | ||
| Request a prescription for ephedrine |
Correct Answer:
Rationale:
To determine the correct answer, we must consider the implications of an epidural insertion. Decreasing the IV flow rate is essential to prevent hypotension which can occur due to the epidural anesthesia. Monitoring fetal heart rate is essential to ensure fetal well-being. Administering ampicillin IV and requesting ephedrine are not directly related to the client's condition post-epidural, so they are contraindicated. Placing the client in the left lateral position helps to optimize blood flow to the placenta and is essential post-epidural.
Therefore, the correct answer is .
Extract:
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.
Question 2 of 5
A nurse in an antepartum unit is caring for a client., For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia: A. Purulent amniotic fluid, B. Elevated uric acid level, C. Fever, D. Decreased platelet count, E. Blurred vision.
Correct Answer: A,C,B,D,E
Rationale: The correct answer is A, C, B, D, E.
A. Purulent amniotic fluid is consistent with chorioamnionitis, an infection of the amniotic fluid and membranes.
C. Fever is a common sign of both chorioamnionitis and preeclampsia but is more specific to chorioamnionitis.
B. Elevated uric acid level is more indicative of preeclampsia due to impaired kidney function.
D. Decreased platelet count is a sign of preeclampsia, indicating potential liver dysfunction.
E. Blurred vision is a hallmark sign of severe preeclampsia due to elevated blood pressure affecting the retina.
Therefore, the correct answer includes findings that are specific to both chorioamnionitis and preeclampsia, providing a comprehensive assessment approach.
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 3 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 4 of 5
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Nervousness. A blood glucose level of 64 mg/dL indicates hypoglycemia in a client with type 1 diabetes. Nervousness is a common symptom of hypoglycemia due to the body's stress response to low blood sugar. Tachypnea (choice
A) is more likely to be seen in diabetic ketoacidosis. Ketonuria (choice
B) is a sign of hyperglycemia and ketosis, not hypoglycemia. Warm skin (choice
C) is not specific to any particular blood glucose level.
Therefore, the nurse should expect the client to display nervousness as a result of the low blood glucose level.
Extract:
Admission Assessments: Client admitted to labor and delivery. Gravida 1, para 0 at 40 weeks of gestation, presents with contractions every 5 to 6 min, 30 to 40 seconds duration, 2+ intensity. Client reports their water broke and the fluid was clear. Positive for group B Streptococcus B-hemolytic at 37 weeks. Sterile vaginal examination. Cervix 5 cm dilated, 50% effaced, and 0 station. Flow Sheet: 1130:
Fetal heart rate 140/min with moderate variability. Intermittent accelerations. Contractions moderate, average 80 seconds duration.
1210:
Fetal heart rate 140/min with moderate variability. Early deceleration. Contractions moderate, average 90 seconds duration.
1215:
Fetal heart rate 120/min with minimal variability Early decelerations. Vital Sign:1130:
Temperature 36.4° C (97.5° F)
Heart rate 84/min
Respiratory rate 18/min
BP 124/82 mm Hg
1200:
Temperature 36.5° C (97.7° F)
Heart rate 90/min.
Respiratory rate 18/min
BP 128/84 mm Hg
1215:
Temperature 37.1° C (98.8° F)
Heart rate 86/min
Respiratory rate 18/min
BP 120/80 mm Hg
Question 5 of 5
The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client: A. Decrease the IV flow rate, B. Monitor fetal heart rate, C. Administer ampicillin IV, D. Place client in left lateral position, E. Request a prescription for ephedrine.
| Options | Essential | Contrainidication |
|---|---|---|
| Decrease the IV flow rate | ||
| Monitor fetal heart rate | ||
| Administer ampicillin IV | ||
| Place client in left lateral position | ||
| Request a prescription for ephedrine |
Correct Answer:
Rationale:
To determine the correct answer, we must consider the implications of an epidural insertion. Decreasing the IV flow rate is essential to prevent hypotension which can occur due to the epidural anesthesia. Monitoring fetal heart rate is essential to ensure fetal well-being. Administering ampicillin IV and requesting ephedrine are not directly related to the client's condition post-epidural, so they are contraindicated. Placing the client in the left lateral position helps to optimize blood flow to the placenta and is essential post-epidural.
Therefore, the correct answer is .