ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A school nurse is developing a teaching plan about testicular cancer for a group of clients. Which of the following information should the nurse include in the teaching?
- A. Perform a testicular self-examination weekly.
- B. Do not palpate the epididymis when performing a testicular self-examination.
- C. Expect testicles to be uniform in consistency when performing a testicular self-examination.
- D. Perform a testicular self-examination after a cool shower.
Correct answer: C
Rationale: The correct answer is C because testicles should be uniform in consistency when performing a self-exam, and any lumps or abnormalities should be reported. Choice A is incorrect as testicular self-examinations should be performed monthly, not weekly. Choice B is incorrect because the epididymis should be included in the examination. Choice D is incorrect because a warm shower helps relax the scrotum, making the exam easier to perform.
2. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?
- A. Report any urine output greater than 30 mL/hr.
- B. Bruising on the arms and legs.
- C. Positive Trousseau's sign.
- D. Urine output of 60 mL/hr.
Correct answer: B
Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.
3. What are the nursing priorities when caring for a patient with a newly placed peripherally inserted central catheter (PICC)?
- A. Performing sterile dressing changes
- B. Educating the patient on PICC line care
- C. Flushing the PICC line as prescribed
- D. Inspecting the insertion site for signs of infection
Correct answer: A
Rationale: The correct answer is A: Performing sterile dressing changes. When caring for a patient with a newly placed PICC line, one of the nursing priorities is to ensure proper care of the insertion site by performing sterile dressing changes. This helps prevent infections and maintain the integrity of the line. While educating the patient on PICC line care, flushing the PICC line as prescribed, and inspecting the insertion site for signs of infection are important aspects of care, the priority immediately after insertion is to maintain the sterility of the site through proper dressing changes.
4. A client with neuropathic pain has a new prescription for amitriptyline once per day. What should the nurse include in the teaching?
- A. Take the medication with meals
- B. Increase fluids while on this medication
- C. Take it only at night
- D. Report any yellowing of the skin
Correct answer: B
Rationale: The correct answer is B: 'Increase fluids while on this medication.' Amitriptyline can cause side effects like dry mouth and urinary retention. Increasing fluids can help alleviate these side effects. Choices A, C, and D are incorrect. Taking the medication with meals or only at night is not specifically related to managing the side effects of amitriptyline. Reporting yellowing of the skin is important but not directly related to the side effects of this medication.
5. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
- A. Self-report of pain
- B. Nonverbal behavior
- C. Severity of the condition
- D. Vital signs
Correct answer: A
Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.
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