RN ATI Capstone Proctored Comprehensive Assessment 2019 A with Rationales

1. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? - Elevate the affected leg - Rationale: the nurse should elevate the client’s affected extremity to reduce edema and decrease the risk of chronic venous insufficiency 2. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? - I should have my child avoid sun exposure between 10 am and 2 pm - Rationale: to prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing and avoid sun exposure between 1000 and 1400 3. A nurse is providing teaching about infection prevention to a client who has been receiving chemotherapy. Which of the following statements by the client indicated an understanding of the teaching? - “I will walk for short distances throughout the day” - Rationale: The client should ambulate for short distances as tolerated throughout the day. This will help to reduce pulmonary stasis and prevent the development of respiratory infections. 4. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? - Introduce new foods one at a time over 5 to 7 days - Rationale: The parent should introduce new foods one at a time over 5 to 7 days to identify potential food allergies 5. A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan of care? - Provide a staff member to stay with the client continuously - Rationale: a staff member must remain continuously with a client who is in restraints or view the client via audiovisual equipment, if necessary, due to risk of injury. 6. A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? - Performing a rapid needs assessment - Rationale: disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage. 7. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurser requires the nurse manager to intervene? - Tells the hospital chaplain a client’s diagnosis - Rationale: discussing a client’s diagnosis with the hospital chaplain is a breach of client confidentiality and a violation of HIPAA 8. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? - Continue observing the fetal heart rate - Rationale: early decelerations indicate the progression of labor and are an expected finding. The nurse should monitor the fetus by observing the fetal heart rate and tracing. 9. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff’s acceptance of this change, which of the following actions should the nurse manager take first? - Provide information about scheduling issues to the staff - Rationale: the first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why the changes are necessary. 10. A nurse is planning teaching about allowable foods for a client who has a history of uric acidbased urinary calculi formation. Which of the following foods should the nurse include in the teaching? - Oranges - Rationale: a client who is prone to uric acid calculi formation can eat citrus fruits 11. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? - The cervix transitions to an anterior position - Rationale: in true labor the cervix transitions to an anterior position and begins to filate in the preparation for birth. 12. A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? - The client is able to accurately describe the upcoming procedure - Rationale: the ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client, and that the client is able to sign the informed consent form 13. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? - Ask the nurse about their knowledge of the procedure - Rationale: the first action the charge nurse should take nursing the nursing process is to assess the newly licensed nurse’s knowledge about the procedure. By assessing the nurse’s knowledge the charge nurse can identify the nurse’s learning needs. 14. A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? - Headaches - Rationale: the nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events. 15. Dosage problem: we already know this shi* 16. A nurse is caring for a client who is 12 hours postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 minutes. Which of the following staff members should the nurse assign to collect this information? - An assistive personnel (AP) who is assisting a client to return to bed - Rationale: Performing a blood pressure check is within the range of function of an AP, and the AP should be available to obtain a blood pressure within the specified time. 17. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? - Withhold administering the varicella vaccine to the child - Rationale: a child who has immunodeficiency should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed. 18. A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? SATA - A speech pathologist will be performing a swallowing study for you - Rationale: the nurse should instruct the client that a swallowing study will be performed to determine the client’s risk for aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. - You should rest before eating a meal - Rationale: The nurse should encourage the client to rest before each meal. Clients who have multiple sclerosis often report weakness and are easily fatigued. - Thicken your beverages before drinking - Rationale: the nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. 19. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report to the provider? - Temperature 39.4 C (102.9 F) - Rationale: the greatest risk to this client is injury from neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a high temperature, dysrhythmia, decreased level of consciousness, and a liable blood pressure. Therefore, the priority finding for the nurse report to the provider is the fever. 20. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering? - Flumazenil - Rationale: The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor antagonist to reverse the sedative effects of lorazepam. In addition, the nurse should continue to support the client’s respirations with a bag-valve mask. 21. A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider? - Audible stridor - Rationale: Audible stridor, or a high-pitched sound heart in the client’s airway indicates edema, laryngeal spasm, secretions, or some type of airway obstruction that could become lifethreatening. The nurse should report this finding to the provider. 22. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain a surgical aseptic technique? - Set the catheter tray on the overbed table at waist height - Rationale: to maintain the sterility, the nurse should place the catheter tray on a work surface at or above waist level. 23. A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take? - Clear objects from the client’s walking area - Rationale: The nurse should plan to clear objects from the clients walking area because CN II is the optic nerve, and a deficit can result in visual impairment which can lead to falls 24. A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? - Install a raised toilet seat at home - Rationale: the client should use a raised toilet seat at home to minimize hip flexion and prevent hip dislocation 25. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? - Low back pain - Rationale: the nurse should expect low back pain in a client who is having a hemolytic transfusion reaction 26. A nurse is caring for a child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? - Place the child in a side-lying position - Rationale: the nurse should place the child in a side-lying position during a seizure to maintain a patent airway, decrease the risk of aspiration, and facilitate drainage of oral secretions. 27. A nurse is administering medications to a client who has a percutaneous gastronomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? - Flush the client’s gastronomy tube with 30 mL of water before administering the medication - Rationale: the nurser should flush the gastronomy tube with at least 30 mL of water before and after medication administration to clear the tube of any residuals and to ensure patency. 28. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? - Decreased central vision - Rationale: the nurse should expect a client who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina. 29. “Big bob car the boat is bouncing back” is an example of what speech alteration? - Clang association - Rationale: clang association is an alteration in speech in which the client uses words based on their sound rather than their meaning. Clients who have neurological disorders can also have this alteration in speech. 30. A nurse in a clinic receives a call from a guarding whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make? - “When crusts have formed on every lesion” - Rationale: The child should return to school once all lesions have crusted over. Varicella is no longer contagious after crusts have formed on all lesions 31. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? - “I should report a change in the color of my stools” - Rationale: The nurse should inform the client that red, black or tarry stools can indicate bleeding, an adverse effect of warfarin, and the client should report these findings to the provider 32. The nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? - Hemoptysis 275 Ml/24 HR - Rationale: hemoptysis greater than 250 Ml/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report. 33. When caring for a child, a nurse plans to use non pharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child’s discomfort? - Blowing bubbles with liquid soap to “blow the hurt away” - Rationale: having the child blow bubbles is a visualization technique that can help decrease the child’s discomfort. The child can visualize the pain as the bubble they blow away from themselves and into the air. 34. An assistive personal (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? - Places a pillow under the client’s right arm - Rationale: the AP should place a pillow under the client’s left arm to prevent internal rotation of the left shoulder 35. A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? - Document the client’s refusal of the medication - Rationale: the client has the right to refuse medication. The nurse should document the refusal on the client’s medical record. 36. A nurse is caring for four clients. Which of the following clients should the nurse assign to the assistive personnel (AP) to assist with meals? - A client who has Alzheimer’s disease and is demonstrating aphasia - Rationale: aphasia impairs the client’s ability to communicate but does not interfere with nutritional intake or place the client at an increased risk for aspiration while eating. Therefore assisting the client with meals is within the AP’s range of function. 37. A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? - Establish the termination date of therapy - Rationale: This task occurs in the orientation phase of a therapeutic relationship 38. A nurse is caring for a client who is 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? - “The enlarged uterus compresses the intestines and causes constipation” - Rationale: During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in mobility, leading to constipation. 39. A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0500 and 0730. Which of the following actions should the nurse take when conducting the root cause analysis? - Investigate environmental factors that might be contributing to client injury during these hours. 40. A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? - Measure the client’s vital signs - Rationale: The first action the nurse should take when using the nursing process is to assess the client. The nurse should monitor the client’s vital signs every 15 minutes until stable and then every 4 hours for the next 48 hours. 41. A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? - The family can have the child in an open casket without fearing that the organ donation might disfigure the child’s body - Rationale: removal of organs does not damage or violate the child’s body in a way that would prevent an open casket funeral. 42. A nurse is teaching about a parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of following information should the nurse include? - “You will receive fingerstick for blood glucose testing” - Rationale: a client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring. 43. A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hours. Which of the following assessment findings should the nurse identify as the priority? - The client’s heel is reddened and tender - Rationale: the greatest risk to this client is the injury from a pressure injury. Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel. 44. A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? - Use hydrogen peroxide to clean kitchen surfaces - Rationale: the client should clean kitchen surfaces with hydrogen peroxide to kill the virus and prevent transmission 45. Catheter for urinary retention? - Straight urinary catheter - Rationale: straight catheter is for intermittent catheterization 46. A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? - Identify health-related issues within the community - Rationale: the first action the nurse should take when using the nursing process is to assess the clients living in the community to identify the prevalent health problems 47. A nurse is caring for a client who has generalized anxiety disorder and it to begin taking alprazolam. Which of the following actions should the nurse take? - Initiate fall precautions for the client - Rationale: the nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion and lethargy. 48. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? - Dry the newborn - Rationale: the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take is to dry the newborn. 49. A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client’s plan of care? - Supervise the client during and after eating - Rationale: the nurse should monitor the client during and for 1 hour after meals to prevent the client from hiding food or purging 50. A nurse is talking with a partner of a client who attempted suicide. Which of the following statements by the client’s partner should the nurse identify as the priority? - “My husband doesn’t know that I’ve already moved out of the house and filed for a divorce” - Rationale: a lack of social support and isolation indicates the client is at greatest risk for another suicide attempt. Therefore, this is the priority concern that the nurse should report to the provider. 51. A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? - Nystagmus - Rationale: Nystagmus is involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis. 52. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client’s safety, which of the following actions should the nurse take first? - Determine the client’s perception of the personal impact of the crisis - Rationale: the first action the nurse should take using the nursing process is to assess the client. Therefore, the first action the nurse should take is to determine the client’s feelings and understanding of the natural disaster and its personal impact. 53. Where should the nurse administer enoxaparin? - Subcutaneous muscle - Rationale: the periumbilical area is where the injection goes