ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?
- A. Brachial pulse in the right arm
- B. Radial pulse in the right arm
- C. Brachial pulse in the left arm
- D. Radial pulse in the left arm
Correct answer: D
Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.
2. The nurse is conducting discharge teaching with the parent of a 7-year-old child with minimal change nephrotic syndrome (MCNS). What statement by the parent indicates a correct understanding of the teaching?
- A. My child needs to stay home from school for at least 1 more month.
- B. I should not add additional salt to any of my child's meals.
- C. My child will not be able to participate in contact sports while receiving corticosteroid therapy.
- D. I should measure my child's urine after each void and report the 24-hour amount to the healthcare provider.
Correct answer: B
Rationale: Avoiding additional salt is crucial to help manage edema in children with MCNS. While monitoring urine output is important, the other statements either misinterpret the need for prolonged school absence or misunderstand the risk associated with contact sports during steroid therapy.
3. A nurse is assessing a client who has a history of urinary incontinence. Which of the following findings should the nurse report to the provider?
- A. Urine output of 50 mL in 2 hours
- B. Presence of an indwelling urinary catheter
- C. Frequent urination at night
- D. Dark-colored urine
Correct answer: D
Rationale: The correct answer is D, dark-colored urine. Dark-colored urine can indicate various issues such as dehydration, liver problems, or blood in the urine, which could be concerning and require further evaluation by the provider. Choices A, B, and C are not necessarily findings that would need immediate reporting to the provider. A urine output of 50 mL in 2 hours might be low but could be influenced by various factors and might not always require immediate action. The presence of an indwelling urinary catheter is a known history and not a new finding. Frequent urination at night could be a symptom related to various conditions but may not be an urgent concern unless accompanied by other significant symptoms.
4. A client with schizophrenia starting therapy with clozapine is being discharged. Which symptom should the client report to the provider as the highest priority?
- A. Constipation
- B. Blurred vision
- C. Fever
- D. Dry mouth
Correct answer: C
Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.
5. A client has Clostridium difficile infection. Which of the following actions should the nurse take?
- A. Wash hands with an alcohol-based hand rub.
- B. Place the client on contact precautions.
- C. Wear a mask when entering the client's room.
- D. Double-bag all linens before removing them from the room.
Correct answer: B
Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.
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