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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. 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.
2. A healthcare professional is teaching a client about reducing the risk of urinary tract infections (UTIs). Which factor increases the risk of UTI?
- A. Wearing underwear with a cotton crotch
- B. Wiping from front to back
- C. Using perfumed toilet paper
- D. Urinating after intercourse
Correct answer: C
Rationale: Using perfumed toilet paper can irritate the urinary tract and increase the risk of UTI, so it should be avoided. Wearing underwear with a cotton crotch (Choice A) is a preventive measure as cotton allows for better air circulation and reduces moisture, lowering the risk of UTIs. Wiping from front to back (Choice B) helps prevent the introduction of bacteria from the anal region to the urinary tract. Urinating after intercourse (Choice D) can help flush out bacteria introduced during sexual activity, thereby reducing the risk of UTIs.
3. 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.
4. 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.
5. While assessing four clients, which client data should be reported to the provider?
- A. Client with pleurisy who reports a pain level of 6 out of 10 when coughing
- B. Client with 110 mL of serosanguineous fluid from a JP drain
- C. Client 4 hours postoperative with a heart rate of 98 bpm
- D. Client undergoing chemotherapy with an absolute neutrophil count of 75/mm³
Correct answer: D
Rationale: An absolute neutrophil count of 75/mm³ is critically low and places the client at high risk for infection, necessitating immediate intervention. Neutropenia increases susceptibility to infections, making it essential to report this finding promptly. The other options, such as pain level in pleurisy, drainage amount from a drain, and heart rate postoperatively, are important but do not indicate an immediate life-threatening condition that requires urgent provider notification.
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