ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A healthcare provider is assessing a client who has been using beclomethasone for 2 weeks to manage her asthma. What is the priority to report to the provider?
- A. Sore throat
- B. Cough
- C. Chest tightness
- D. Bronchospasms
Correct answer: D
Rationale: The correct answer is D: Bronchospasms. Bronchospasms can indicate worsening asthma and are considered a severe side effect that requires immediate attention. While sore throat, cough, and chest tightness are also possible side effects of beclomethasone, bronchospasms are of higher concern due to their association with significant respiratory distress and potential exacerbation of asthma symptoms.
2. A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?
- A. I will monitor my husband for coughing while he is eating
- B. I will monitor my husband for pocketing food in his mouth
- C. I will monitor for a change in my husband's voice after he swallows
- D. I will monitor my husband for tilting his head forward when he swallows
Correct answer: D
Rationale: The correct answer is D. Tilting the head forward during swallowing is not a compensatory technique for dysphagia and may increase the risk of aspiration. Choices A, B, and C are correct statements indicating appropriate monitoring for manifestations of dysphagia: coughing while eating, pocketing food in the mouth, and changes in voice after swallowing are all signs that should be monitored.
3. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?
- A. Monitor the patient's blood pressure regularly.
- B. Change the CVC dressing every 72 hours.
- C. Flush the CVC with normal saline every shift.
- D. Avoid using the CVC for blood draws.
Correct answer: B
Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.
4. A healthcare professional is caring for a client with impaired mobility. Which of the following support devices should the healthcare professional plan to use to prevent the client from developing plantar flexion contractures?
- A. Sheepskin heel pad
- B. Footboard
- C. Trochanter roll
- D. Abduction pillow
Correct answer: B
Rationale: A footboard is the correct choice to prevent plantar flexion contractures by maintaining proper alignment of the feet. Plantar flexion contractures involve the foot pointing downward, and a footboard helps keep the foot in a neutral position. Choice A, the sheepskin heel pad, is used for pressure ulcer prevention and comfort but does not specifically address plantar flexion contractures. Choice C, the trochanter roll, is used for hip positioning, not foot alignment. Choice D, the abduction pillow, is used to maintain proper positioning of the legs but does not directly address plantar flexion contractures.
5. Which question is essential during screening for alcohol use disorder?
- A. What is your current employment status?
- B. Have you experienced any blackouts or loss of consciousness?
- C. Have you been sleeping well over the past month?
- D. Do you have a family history of substance use?
Correct answer: B
Rationale: The essential question during screening for alcohol use disorder is asking about blackouts or loss of consciousness, which can be indicative of excessive drinking and related to alcohol use disorder. Choices A, C, and D are not as directly related to screening for alcohol use disorder. Employment status (Choice A) is not a primary question in alcohol use disorder screening. Sleep quality (Choice C) and family history of substance use (Choice D) may be relevant but are not as crucial as inquiring about blackouts or loss of consciousness.
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