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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a toddler with respiratory syncytial virus (RSV). Which action should the nurse take?
- A. Use a designated stethoscope for the toddler
- B. Wear an N95 respirator mask when caring for the toddler
- C. Place the toddler in a negative pressure room
- D. Remove the disposable gown before leaving the toddler's room
Correct answer: A
Rationale: Using a designated stethoscope for the toddler is crucial to reduce the risk of spreading RSV to other patients. Choice B is incorrect because N95 respirator masks are not specifically indicated for RSV. Choice C is unnecessary as RSV does not require isolation in a negative pressure room. Choice D is incorrect because the gown should be removed after leaving the room to prevent transmission of pathogens to other areas.
2. A nurse is assessing a client with suspected myocardial infarction. Which finding should the nurse report to the provider?
- A. Pain radiating to the left arm
- B. Pain relieved by rest
- C. Pain worsened with breathing
- D. Pain relieved by antacids
Correct answer: A
Rationale: The correct answer is A: Pain radiating to the left arm. This is a classic symptom of myocardial infarction and indicates possible heart involvement. Reporting this finding to the provider is crucial for prompt evaluation and intervention. Choices B, C, and D are incorrect. Pain relieved by rest, pain worsened with breathing, and pain relieved by antacids are not typical symptoms of myocardial infarction. These findings do not raise the same level of concern as pain radiating to the left arm and are less indicative of cardiac involvement.
3. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct answer: A
Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.
4. A nurse is teaching a client about nonpharmacological pain management techniques. Which statement about hypnosis is appropriate?
- A. Hypnosis promotes increased control of pain perception during labor
- B. Hypnosis uses therapeutic touch to reduce anxiety
- C. Hypnosis focuses on biofeedback as a relaxation technique
- D. Hypnosis provides instruction to minimize pain
Correct answer: A
Rationale: The correct answer is A: "Hypnosis promotes increased control of pain perception during labor." Hypnosis can be effectively utilized during labor to help individuals enhance their control over how they perceive pain. Choice B is incorrect because hypnosis does not primarily use therapeutic touch to reduce anxiety. Choice C is incorrect as hypnosis is not primarily focused on biofeedback as a relaxation technique. Choice D is incorrect because hypnosis does not provide direct instructions to minimize pain but rather helps individuals gain control over their pain perception.
5. A client with severe preeclampsia is receiving magnesium sulfate intravenously. Which action should the nurse take when toxicity occurs?
- A. Position the client supine
- B. Prepare an IV bolus of dextrose 5%
- C. Administer calcium gluconate IV
- D. Administer methylergonovine IM
Correct answer: C
Rationale: When toxicity from magnesium sulfate occurs, the nurse should administer calcium gluconate IV as it is the antidote for magnesium sulfate toxicity. Positioning the client supine may not address the toxicity issue. Administering dextrose 5% is not the appropriate intervention for magnesium sulfate toxicity. Methylergonovine is used to manage postpartum hemorrhage and is not indicated for magnesium sulfate toxicity.
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