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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?
- A. Sunken anterior fontanel
- B. Tenting skin turgor
- C. Flat anterior fontanel
- D. Hyperpnea
Correct answer: C
Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.
2. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?
- A. Blood glucose of 150 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic blood pressure of 140 mm Hg
- D. BUN 20 mg/dL
Correct answer: B
Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.
3. A nurse is caring for a client with hepatic encephalopathy. Which food selection indicates an understanding of dietary teaching?
- A. Cottage cheese
- B. Tuna salad
- C. Rice with black beans
- D. Three-egg omelet
Correct answer: C
Rationale: The correct answer is C: 'Rice with black beans.' Clients with hepatic encephalopathy should limit animal proteins due to their high ammonia content, which can exacerbate symptoms. Plant-based proteins like beans are preferred as they help reduce ammonia levels. Choices A, B, and D contain animal proteins that are not ideal for clients with hepatic encephalopathy.
4. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?
- A. Take vital signs
- B. Assess lochia
- C. Massage the fundus
- D. Give oxytocin IV bolus
Correct answer: C
Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.
5. A nurse is caring for a client who sprained his ankle 12 hours ago. Which of the following provider prescriptions should the nurse question?
- A. Elevate the affected extremity on two pillows
- B. Apply heat to the affected extremity for 45 minutes
- C. Wrap the extremity with a compression dressing
- D. Assess sensation, movement, and pulse every 4 hours
Correct answer: B
Rationale: The nurse should question the prescription to apply heat to the affected extremity for 45 minutes. Heat should not be applied in the first 48 hours after an acute injury, as it can increase swelling. Cold therapy is more appropriate initially. Choices A, C, and D are appropriate actions in the care of a client with a sprained ankle. Elevating the affected extremity helps reduce swelling, wrapping it with a compression dressing provides support, and assessing sensation, movement, and pulse every 4 hours is important to monitor for complications.
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