ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A healthcare provider is planning care for a client who has fluid overload. Which of the following actions should the provider plan to take first?
- A. Assess for edema
- B. Evaluate electrolytes
- C. Restrict fluid intake
- D. Administer diuretics
Correct answer: B
Rationale: Evaluating electrolytes is crucial when addressing fluid overload as it helps determine the severity of the imbalance and guides treatment. Assessing for edema (Choice A) is important but not the priority over evaluating electrolytes. Restricting fluid intake (Choice C) and administering diuretics (Choice D) are interventions that may be necessary but should be based on the electrolyte evaluation to ensure safe and effective care.
2. For a complete spinal injury, which statement is true?
- A. Some of the motor and sensory functions are lost
- B. Only the motor functions are lost
- C. Only the sensory functions are lost
- D. Both the motor and sensory functions are lost
Correct answer: D
Rationale: In a complete spinal injury, there is total loss of motor and sensory functions below the level of the injury. This means that both motor (ability to move) and sensory (ability to feel) functions are affected. It is important to distinguish between complete and incomplete spinal injuries, as complete injuries result in the loss of all functions below the level of injury, while incomplete injuries allow for some preservation of motor or sensory functions.
3. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
- A. Redness at the catheter insertion site
- B. Report of headache and stiff neck
- C. Temperature of 100.1 F (37.8 C)
- D. Pain rating of 8 on a scale of 0 to 10
Correct answer: Report of headache and stiff neck
Rationale:
4. What is the correct sequence for assessing the abdomen?
- A. Tympanic percussion, measurement of abdominal girth, and inspection
- B. Assessment for distention, tenderness, and discoloration around the umbilicus
- C. Percussion, palpation, and auscultation
- D. Auscultation, percussion, and palpation
Correct answer: D
Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.
5. A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?
- A. Serum glucose level.
- B. Serum calcium level.
- C. Lymphocyte count.
- D. Serum potassium level.
Correct answer: A
Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, elevated cortisol levels lead to increased gluconeogenesis, insulin resistance, and breakdown of proteins and fats, resulting in elevated blood glucose levels. This is known as hyperglycemia. The other options, including serum calcium level (choice B), lymphocyte count (choice C), and serum potassium level (choice D), are not typically affected by Cushing's disease. Therefore, they are incorrect choices.
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