ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A nurse is caring for a client with a new colostomy. What is the nurse's responsibility regarding stoma care?
- A. Educate the client on how to care for the stoma independently.
- B. Contact the stoma nurse to assist the client with care.
- C. Delegate the care of the stoma to a nursing assistant.
- D. Wait until the next shift to address the stoma care.
Correct answer: B
Rationale: The correct answer is to contact the stoma nurse to assist the client with care. Stoma nurses are specially trained to provide guidance on stoma care, especially for clients with new ostomies. Instructing the client to care for the stoma independently (Choice A) may not be appropriate initially as they may need professional guidance. Delegating the care of the stoma to a nursing assistant (Choice C) is not recommended as specialized care is required. Waiting until the next shift (Choice D) is not ideal as stoma care should not be delayed.
2. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease?
- A. Diarrhea
- B. Hypermenorrhea
- C. Abnormal bleeding
- D. Abdominal distention
Correct answer: D
Rationale: Abdominal distention is a common symptom in advanced ovarian cancer due to several factors, including the accumulation of ascites (fluid in the abdominal cavity) and the presence of tumors that can increase abdominal girth. As the disease progresses, the pressure from growing masses or fluid buildup can lead to noticeable swelling and discomfort in the abdomen. This symptom often prompts further evaluation and can significantly impact the patient’s quality of life.
3. A client has a new prescription for Calcitonin-salmon for postmenopausal osteoporosis. Which of the following instructions should the nurse include in the teaching?
- A. Swallow tablets on an empty stomach with plenty of water.
- B. Watch for skin rash and redness when applying calcitonin-salmon topically.
- C. Mix the liquid medication with juice and take it after meals.
- D. Alternate nostrils each time calcitonin-salmon is inhaled.
Correct answer: D
Rationale: Calcitonin-salmon is commonly administered intranasally for postmenopausal osteoporosis. It is essential to alternate nostrils daily when inhaling the medication to ensure equal distribution and optimal absorption. This technique helps prevent irritation and congestion in one nostril and enhances the effectiveness of the medication. Choices A, B, and C are incorrect because calcitonin-salmon is not swallowed, applied topically, or taken as a liquid medication after meals. Therefore, instructing the client to alternate nostrils during inhalation is the most appropriate teaching for this medication.
4. A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following comp
- A. Placenta previa
- B. Prolapsed cord
- C. Incompetent cervix
- D. Abruptio placentae
Correct answer: Abruptio placentae
Rationale:
5. A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions?
- A. Airborne
- B. Standard
- C. Contact
- D. Droplet
Correct answer: Airborne
Rationale: The correct answer is 'Airborne.' Varicella (chickenpox) is caused by the varicella-zoster virus, which spreads through the air by respiratory droplets. Therefore, placing the client on airborne precautions is necessary to prevent the transmission of the virus. Choice B, 'Standard precautions,' involve basic infection prevention measures that are used for all client care. Choice C, 'Contact precautions,' are used for diseases that spread by direct or indirect contact. Choice D, 'Droplet precautions,' are implemented for diseases transmitted by respiratory droplets that are larger than 5 microns.
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