ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notices clots in the client's urinary catheter and decreased urinary output. Which of the following actions should the nurse take?
- A. Administer an antispasmodic
- B. Irrigate the catheter with 0.9% sodium chloride irrigation
- C. Apply gentle manual pressure to the bladder
- D. Clamp the catheter tubing
Correct answer: B
Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation. This action helps clear the clots in the catheter and restore proper urine flow after a TURP. Administering an antispasmodic (Choice A) is not the appropriate action for clots in the catheter and decreased urinary output. Applying gentle manual pressure to the bladder (Choice C) or clamping the catheter tubing (Choice D) could potentially worsen the situation by causing bladder distention or preventing urine drainage.
2. Which parental statement at the end of a teaching session by the nurse indicates correct understanding of colostomy stoma care for the infant client?
- A. We will change the colostomy bag with each wet diaper.
- B. We will expect a moderate amount of bleeding after cleansing the area around the stoma.
- C. We will watch for skin irritation around the stoma.
- D. We will use adhesive enhancers when we change the bag.
Correct answer: C
Rationale: Choosing option C, 'We will watch for skin irritation around the stoma,' demonstrates understanding of proper colostomy stoma care. Monitoring for skin irritation is crucial as it can indicate issues such as leakage, improper sealing, or infection. Options A, B, and D are incorrect. Changing the colostomy bag with each wet diaper (option A) is unnecessary unless indicated by a healthcare provider to prevent skin breakdown. Expecting bleeding after cleansing (option B) is not normal and may signal a problem that requires medical attention. Using adhesive enhancers (option D) should be done based on specific recommendations and not necessarily with every bag change.
3. In a postmenopausal woman, what condition can be prevented by administering estradiol (Estraderm)?
- A. Endometriosis
- B. Amenorrhea
- C. Osteoporosis
- D. Uterine cancer
Correct answer: C
Rationale: The correct answer is C: Osteoporosis. Estradiol, a form of estrogen, is used to prevent osteoporosis in postmenopausal women by maintaining bone density. Choice A, Endometriosis, is incorrect as estradiol is not used to prevent or treat this condition. Choice B, Amenorrhea, is not prevented by estradiol but rather may result from hormonal changes. Choice D, Uterine cancer, is not directly prevented by estradiol; in fact, long-term unopposed estrogen use can increase the risk of uterine cancer.
4. Which action demonstrates secondary prevention?
- A. Screening for early signs of disease
- B. Providing rehabilitation services
- C. Administering medications
- D. Providing health education
Correct answer: A
Rationale: The correct answer is A: Screening for early signs of disease. Secondary prevention involves activities that aim to detect health issues early to provide timely treatment. Screening for early signs of disease falls under secondary prevention as it helps identify diseases in their early stages, allowing for prompt intervention and management.
5. A healthcare professional is preparing to administer the initial dose of ceftriaxone to a client who has endometritis. Which of the following statements by the client should cause the healthcare professional to hold the medication and consult the provider?
- A. I have a severe allergy to amoxicillin
- B. I get sick when I take diuretics
- C. I have a history of hearing problems
- D. I take prednisone for my asthma
Correct answer: A
Rationale: A severe allergy to amoxicillin could indicate a potential cross-reactivity with ceftriaxone, so the medication should be held. Cross-reactivity between penicillins (like amoxicillin) and cephalosporins (like ceftriaxone) is a known concern due to their similar chemical structures. Choices B, C, and D do not directly contraindicate the administration of ceftriaxone for endometritis.
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