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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client 4 hours postoperative following a thyroidectomy who reports fullness in the throat. What should the nurse assess for?
- A. Hypocalcemia
- B. Hemorrhage
- C. Hypoxia
- D. Hypothyroidism
Correct answer: B
Rationale: Fullness in the throat after a thyroidectomy could indicate bleeding or a hematoma, which can compress the airway, so hemorrhage is the priority concern. Hypocalcemia typically presents with symptoms like tingling around the mouth or in the extremities, muscle cramps, or seizures, not fullness in the throat. Hypoxia would manifest with symptoms like shortness of breath, confusion, or cyanosis, rather than a feeling of fullness in the throat. Hypothyroidism symptoms include fatigue, weight gain, and cold intolerance, but it does not typically cause acute fullness in the throat postoperatively.
2. A nurse is planning care for a client who has chronic renal failure. Which action should the nurse include in the plan of care?
- A. Encourage increased fluid intake
- B. Restrict protein intake to the RDA
- C. Increase dietary potassium
- D. Encourage foods high in sodium
Correct answer: B
Rationale: The correct action the nurse should include in the plan of care for a client with chronic renal failure is to restrict protein intake to the RDA. This is important because limiting protein helps reduce the buildup of waste products that the kidneys are unable to efficiently excrete. Encouraging increased fluid intake (choice A) may further burden the kidneys, increasing the risk of fluid overload. Increasing dietary potassium (choice C) is not recommended in chronic renal failure as impaired kidneys have difficulty regulating potassium levels. Encouraging foods high in sodium (choice D) is also not appropriate as excessive sodium intake can lead to fluid retention and hypertension, which are detrimental in renal failure.
3. A nurse is caring for a client with a sealed radiation implant. Which action should the nurse take?
- A. Remove dirty linens after double-bagging
- B. Wear a dosimeter badge
- C. Limit visitors to 1 hour per day
- D. Ensure family remains 3 feet away from the client
Correct answer: B
Rationale: The correct answer is B: Wear a dosimeter badge. When caring for a client with a sealed radiation implant, the nurse should wear a dosimeter badge to monitor radiation exposure. This badge helps measure the amount of radiation the nurse is exposed to during care. Choice A is incorrect because removing dirty linens after double-bagging is not directly related to managing radiation exposure. Choice C is incorrect as there is no specific time limit on visitors mentioned in the context of a sealed radiation implant. Choice D is incorrect as there is no evidence supporting the need for family members to stay a specific distance away from the client.
4. A nurse is planning care for a newly admitted adolescent with bacterial meningitis. What intervention should the nurse include?
- A. Initiate droplet precautions
- B. Assist the client to a supine position
- C. Perform a Glasgow Coma Scale every 24 hours
- D. Recommend prophylactic acyclovir for the client's family
Correct answer: A
Rationale: The correct intervention for a newly admitted adolescent with bacterial meningitis is to initiate droplet precautions. Bacterial meningitis is highly contagious, and droplet precautions are necessary to prevent the spread of infection. Assisting the client to a supine position (Choice B) is not directly related to managing bacterial meningitis. Performing a Glasgow Coma Scale every 24 hours (Choice C) may be important to assess the client's neurological status but is not the priority intervention in preventing the spread of infection. Recommending prophylactic acyclovir for the client's family (Choice D) is not a standard practice in the care of a patient with bacterial meningitis.
5. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?
- A. I will make sure my medications are enteric-coated.
- B. My stoma will drain liquid continuously.
- C. I will change my pouch system every two weeks.
- D. My stoma size will stay the same after it heals.
Correct answer: B
Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.
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