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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 who has Clostridium difficile (C. diff) infection. Which infection control measure should the nurse implement?
- A. Wear a face shield when entering the room
- B. Place the client in a private room
- C. Place the client in a negative pressure room
- D. Use alcohol-based hand rub following client care
Correct answer: B
Rationale: The correct answer is to place the client in a private room. Clostridium difficile (C. diff) infection requires contact precautions, which include isolating the client in a private room to prevent the spread of infection to others. Wearing a face shield may be necessary in certain situations for protection but is not the primary measure for C. diff. Placing the client in a negative pressure room is not specifically indicated for C. diff unless the client has additional respiratory issues. Using alcohol-based hand rub following client care is not sufficient for C. diff control; thorough handwashing with soap and water is recommended due to the spore-forming nature of C. diff.
3. A nurse is reviewing laboratory results for a client receiving chemotherapy. Which result should the nurse report to the provider?
- A. WBC 3,000/mm³
- B. Hemoglobin 12 g/dL
- C. Platelet count 250,000/mm³
- D. Serum sodium 140 mEq/L
Correct answer: A
Rationale: The correct answer is A: WBC 3,000/mm³. A WBC count of 3,000/mm³ indicates neutropenia, which is a condition characterized by a low level of white blood cells, specifically neutrophils. Neutropenia increases the risk of infection and requires immediate medical attention, especially in clients undergoing chemotherapy. Reporting this result to the provider promptly is crucial for further evaluation and intervention. Choices B, C, and D are within normal ranges and do not pose an immediate risk to the client's health. Hemoglobin of 12 g/dL, platelet count of 250,000/mm³, and serum sodium of 140 mEq/L are all normal values and would not typically require immediate reporting unless there are specific concerns related to the individual client's condition.
4. A nurse is teaching a client with mild persistent asthma about montelukast. Which statement by the client indicates understanding?
- A. I will use this for asthma attacks.
- B. I should take this before exercise.
- C. This medication will decrease swelling and mucus production.
- D. I can stop this medication after 10 days.
Correct answer: C
Rationale: Montelukast is a leukotriene receptor antagonist that helps reduce swelling and mucus production in the airways, making it useful for long-term asthma management.
5. A client had a pituitary tumor removed. Which of the following findings requires further assessment?
- A. Glasgow scale score of 15
- B. Blood drainage on dressing measuring 3 cm
- C. Report of dry mouth
- D. Urinary output greater than fluid intake
Correct answer: D
Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.
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