RN ATI Capstone Proctored Comprehensive
Assessment.
1.
A nurse is caring for a client who had abdominal surgery 24 hours ago. Whic of the following
actions is the nurse’s priority?
a. Assess fluid intake every 24 hours
b. Ambulate three times a day
c. Assist with deep breathing and coughing
(this is the nurses priority because ABCs which reduces the risk for postoperative pneumonia)
d. Monitor the incision site for findings of infection
A nurse is conducting group therapy with clients who have breast cancer. The nurse should
recognize which of the following statements by a client is an example of altruism?
a. “I have experienced physical discomfort when intimate with my partner since my
diagnosis”
Conversion. Conversion is the development of physical manifestations in response to anxiety.
b. “I wish other women would stop socializing with my partner”
Projection. Projection is blaming others for unacceptable thoughts and feelings.
c. “I told my doctor that I would like to start a support group for other women who
are sick in my community”
(this is the correct response because altruism is reaching out and helping others)
d. “I used to mistrust my doctor, but now I know that she is the best one to care for me
during my illness”
Splitting. Splitting is the inability to integrate negative and positive attributes of the self or others.
A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which
of the following actions should the nurse take?
a. Assess the client’s IV site every 8 hours
Important to monitor this every 4 hr
b. Check the client’s WBC count every 48 hours
Important to monitor this every 24 hr
c. Monitor the client’s mouth every 8 hours
Monitor the client’s mouth at least every 8 hr for manifestations of an infection, such as sores or
lesions
d. Change the client’s IV tubing every 48 hours
Change the IV tubing every 24 hr for client who has immunosuppression
A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg
cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks.
Which of the following instructions should the nurse include in the teaching?
a. Adjust the crutches for support as needed
A HCP should measure crutches for the client. Clients should not perform their own adjustments
to the crutches. Use of improperly fitting crutches increases the risk of injury from falls.
b. Use a three-point gait
A three-point crutch gait allows the client to be mobile without bearing weight on the affected
extremity
c. Wear leather soled shoes
,RN ATI Capstone Proctored Comprehensive
Assessment
1.
The client should wear rubber-soled shoes when using crutches. The client who wears leather-
soled shoes has an increased risk of slipping and falling.
d. Advance the affected leg first when walking upstairs
When walking upstairs, the client should advance the unaffected leg first. When walking
downstairs, the client should advance the crutches and the affected leg first and then follow with
the unaffected leg.
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites
should the nurse select when initiating the IV for this client?
a. Radial vein of the inner arm
This site will have adequate subcutaneous tissue
b. Great saphenous vein of the leg
This can interfere with the performance of ADLs
c. Dorsal plexus vein of the foot
Veins and vessels in extremities are fragile in older adult clients
d. Basilic vein of the hand
Older adults can have skin that tears easily and can also experience a decreasein
subcutaneous tissue in locations such as hands
A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the
following tasks should the nurse plan to delegate to the AP?
a. Perform gastrostomy feedings through a client’s established gastrostomy tube
The nurse should delegate providing gastrostomy feedings through the client’s established
gastrostomy tube to an AP because this task is within the AP’s range of function
b. Determine if the PRN pain medication administered 30 min ago has helped
RN
c. Provide instructions about client care to a family member over the telephone
RN
d. Teach a client how to measure their own blood pressure
RN
A nurse is providing education to the parent of a school-age child who has asthma. Which of the
following statements by the parent indicates an understanding of the teaching?
a. I will administer aspirin to my child to treat pain or fever
b. I will record an average of three readings from my child’s peak expiratory flow meter
Parent should record highest of three readings rather than average
c. I will place carpet in my child’s bedroom to control allergens
d. I will make sure my child receives a yearly influenza immunization
Type 1 diabetes is a contraindiciation for receiving cold therapy. A client who has type 1
diabetes can have impaired circulation due to arteriosclerosis and a loss of sensory perception
due to neuropathy. Ice can further impair circulation.
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy.
, RN ATI Capstone Proctored Comprehensive
Assessment
1.
Which of the following instructions should the nurse include in the teaching?
a. Check the functioning of oxygen equipment once each week
This should be done daily
b. Wear clothing made with cotton fabrics while oxygen is in use
Cotton fabrics should be used rather than synthetic or woolen fabrics.
c. Apply petroleum-based lubricant to the nares as needed
d. Store full oxygen tanks on their side
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal
cancer. The client tells the nurse that they would like to go home to be with family and loved
onces. Which of the following actions should the nurse take?
a. Contact the facility chaplain to visit with the client
b. Explain the process of leaving the facility against medical advice
c. Make a referral to social services
Obtain referral to ensure that the client’s needs at home are met. They can set up home care or
hospice services for the client if needed
d. Encourage the client to continue with inpatient care
A nurse is caring for a client who has a clogged percutaneous gastronomy feeding tube. Which
of the following actions should the nurse take first?
a. Obtain a prescription for the client to receive an enzyme product
b. Aspirate the client’s tube
c. Flush the client’s tube with 30 ml of water
d. Change the position of the client
Least restrictive intervention first
A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse
should plan to perform which of the following actions?
a. Administer a bowel preparation the night before the procedure
b. Place the client on bed rest for 24 hr after the procedure
c. Perform pulmonary function tests following the procedure
d. Instruct the client to avoid coughing during the procedure
It is important for the nurse to remind the client to avoid coughing and to lie still during a
thoracentesis to avoid puncturing the pleura
A nurse is assessing a client who has COPD. Which of the following findings should the nurse
expect?
a. Weight gain
b. Decrease in anteroposterior diameter of the chest
c. HCO3- 24 mEq/L
d. pH 7.31
Respiratory acidosis is an expected finding for a client who has COPD
A nurse is caring for a client who has a DVT. Which of the following actions should the nurse
Assessment.
1.
A nurse is caring for a client who had abdominal surgery 24 hours ago. Whic of the following
actions is the nurse’s priority?
a. Assess fluid intake every 24 hours
b. Ambulate three times a day
c. Assist with deep breathing and coughing
(this is the nurses priority because ABCs which reduces the risk for postoperative pneumonia)
d. Monitor the incision site for findings of infection
A nurse is conducting group therapy with clients who have breast cancer. The nurse should
recognize which of the following statements by a client is an example of altruism?
a. “I have experienced physical discomfort when intimate with my partner since my
diagnosis”
Conversion. Conversion is the development of physical manifestations in response to anxiety.
b. “I wish other women would stop socializing with my partner”
Projection. Projection is blaming others for unacceptable thoughts and feelings.
c. “I told my doctor that I would like to start a support group for other women who
are sick in my community”
(this is the correct response because altruism is reaching out and helping others)
d. “I used to mistrust my doctor, but now I know that she is the best one to care for me
during my illness”
Splitting. Splitting is the inability to integrate negative and positive attributes of the self or others.
A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which
of the following actions should the nurse take?
a. Assess the client’s IV site every 8 hours
Important to monitor this every 4 hr
b. Check the client’s WBC count every 48 hours
Important to monitor this every 24 hr
c. Monitor the client’s mouth every 8 hours
Monitor the client’s mouth at least every 8 hr for manifestations of an infection, such as sores or
lesions
d. Change the client’s IV tubing every 48 hours
Change the IV tubing every 24 hr for client who has immunosuppression
A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg
cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks.
Which of the following instructions should the nurse include in the teaching?
a. Adjust the crutches for support as needed
A HCP should measure crutches for the client. Clients should not perform their own adjustments
to the crutches. Use of improperly fitting crutches increases the risk of injury from falls.
b. Use a three-point gait
A three-point crutch gait allows the client to be mobile without bearing weight on the affected
extremity
c. Wear leather soled shoes
,RN ATI Capstone Proctored Comprehensive
Assessment
1.
The client should wear rubber-soled shoes when using crutches. The client who wears leather-
soled shoes has an increased risk of slipping and falling.
d. Advance the affected leg first when walking upstairs
When walking upstairs, the client should advance the unaffected leg first. When walking
downstairs, the client should advance the crutches and the affected leg first and then follow with
the unaffected leg.
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites
should the nurse select when initiating the IV for this client?
a. Radial vein of the inner arm
This site will have adequate subcutaneous tissue
b. Great saphenous vein of the leg
This can interfere with the performance of ADLs
c. Dorsal plexus vein of the foot
Veins and vessels in extremities are fragile in older adult clients
d. Basilic vein of the hand
Older adults can have skin that tears easily and can also experience a decreasein
subcutaneous tissue in locations such as hands
A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the
following tasks should the nurse plan to delegate to the AP?
a. Perform gastrostomy feedings through a client’s established gastrostomy tube
The nurse should delegate providing gastrostomy feedings through the client’s established
gastrostomy tube to an AP because this task is within the AP’s range of function
b. Determine if the PRN pain medication administered 30 min ago has helped
RN
c. Provide instructions about client care to a family member over the telephone
RN
d. Teach a client how to measure their own blood pressure
RN
A nurse is providing education to the parent of a school-age child who has asthma. Which of the
following statements by the parent indicates an understanding of the teaching?
a. I will administer aspirin to my child to treat pain or fever
b. I will record an average of three readings from my child’s peak expiratory flow meter
Parent should record highest of three readings rather than average
c. I will place carpet in my child’s bedroom to control allergens
d. I will make sure my child receives a yearly influenza immunization
Type 1 diabetes is a contraindiciation for receiving cold therapy. A client who has type 1
diabetes can have impaired circulation due to arteriosclerosis and a loss of sensory perception
due to neuropathy. Ice can further impair circulation.
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy.
, RN ATI Capstone Proctored Comprehensive
Assessment
1.
Which of the following instructions should the nurse include in the teaching?
a. Check the functioning of oxygen equipment once each week
This should be done daily
b. Wear clothing made with cotton fabrics while oxygen is in use
Cotton fabrics should be used rather than synthetic or woolen fabrics.
c. Apply petroleum-based lubricant to the nares as needed
d. Store full oxygen tanks on their side
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal
cancer. The client tells the nurse that they would like to go home to be with family and loved
onces. Which of the following actions should the nurse take?
a. Contact the facility chaplain to visit with the client
b. Explain the process of leaving the facility against medical advice
c. Make a referral to social services
Obtain referral to ensure that the client’s needs at home are met. They can set up home care or
hospice services for the client if needed
d. Encourage the client to continue with inpatient care
A nurse is caring for a client who has a clogged percutaneous gastronomy feeding tube. Which
of the following actions should the nurse take first?
a. Obtain a prescription for the client to receive an enzyme product
b. Aspirate the client’s tube
c. Flush the client’s tube with 30 ml of water
d. Change the position of the client
Least restrictive intervention first
A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse
should plan to perform which of the following actions?
a. Administer a bowel preparation the night before the procedure
b. Place the client on bed rest for 24 hr after the procedure
c. Perform pulmonary function tests following the procedure
d. Instruct the client to avoid coughing during the procedure
It is important for the nurse to remind the client to avoid coughing and to lie still during a
thoracentesis to avoid puncturing the pleura
A nurse is assessing a client who has COPD. Which of the following findings should the nurse
expect?
a. Weight gain
b. Decrease in anteroposterior diameter of the chest
c. HCO3- 24 mEq/L
d. pH 7.31
Respiratory acidosis is an expected finding for a client who has COPD
A nurse is caring for a client who has a DVT. Which of the following actions should the nurse
