ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Suction the client's airway. When the high-pressure alarm on the ventilator sounds, it indicates that there is an obstruction in the airway. Suctioning helps to clear the airway and prevent further complications. Looking for a leak in the tube's cuff (
B) is not the priority in this situation. Tightening tubing connections (
C) may not address the immediate issue of airway obstruction. Requesting insertion of a tracheostomy tube (
D) is not necessary unless other interventions fail.
Question 2 of 5
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Select a site proximal to previous venipuncture sites. This is important to prevent complications such as phlebitis and infiltration. Choosing a site proximal to previous punctures allows for better vein integrity and minimizes the risk of injury. Options A and B are incorrect as they do not address potential complications or best practices for IV insertion. Option D is incorrect since using a larger gauge catheter can actually increase the risk of phlebitis. Option E, F, and G are not provided. In summary, selecting a site proximal to previous venipuncture sites is crucial for successful IV therapy and minimizing complications.
Question 3 of 5
A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client about the use of telehealth services. This is the most appropriate intervention as it allows the nurse to monitor the client's diabetes management remotely, provide education, and support without the need for the client to travel to a healthcare facility frequently. This intervention promotes independent living while ensuring the client receives necessary care.
A: Discussing a long-term care referral may not be appropriate as the client is still living independently.
B: Reviewing assisted living accommodations is premature and not necessary.
C: Suggesting adult day care may not be relevant for a client who is independent and needs diabetes management.
Overall, option D is the best intervention for this scenario.
Question 4 of 5
A nurse is assessing a client who is taking digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?
Correct Answer: D
Rationale: The correct answer is D: Blurred vision indicates digoxin toxicity. Digoxin toxicity can cause visual disturbances, such as blurred or yellow-tinted vision. This is due to the drug's effects on the optic nerve. Tachycardia (
A) is not a common sign of digoxin toxicity; in fact, digoxin usually slows the heart rate. Hearing loss (
B) and insomnia (
C) are not typical symptoms of digoxin toxicity. Blurred vision is a key indicator of digoxin toxicity and should prompt immediate action to prevent further complications.
Question 5 of 5
A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contractions. The client's blood pressure is 88/50 mm Hg and her abdomen is rigid. The nurse should identify these findings as indicating which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Placental abruption. Placental abruption is characterized by sudden, severe abdominal pain, vaginal bleeding, uterine contractions, low blood pressure, and a rigid abdomen. The abrupt separation of the placenta from the uterine wall can lead to severe maternal and fetal complications. The other choices are incorrect because: B. Amniotic fluid embolus presents with sudden respiratory distress and cardiovascular collapse; C. Placenta previa typically presents with painless vaginal bleeding; D. Uterine rupture may present with sudden abdominal pain but is usually associated with a previous cesarean birth or trauma.