ATI RN Capstone Proctored Comprehensive Assessment Test B

A nurse is caring for a client who had abdominal surgery 24 hours ago. Which of the following actions is the priority? A. Assess fluid intake every 24 hours B. Ambulate three times a day C. Assist with deep breathing and coughing D. Monitor the incision site for findings of infection - C A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism? A. I have experienced physical discomfort when intimate with my partner since my diagnosis B. I wish other women would stop socializing with my partner C. I told my doctor that I would like to start a support group for other women who are sick in my community D. I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness - C 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 clients IV site every 8 hours B. Check the clients WBC count every 48 hours C. Monitor the clients mouth every 8 hours D. Change the clients IV tubing every 48 hours - C A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? A. Eyes area B. Chest area C. Lower abdominal area - C A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A. A client forgets to buy their partner a birthday gift after a disagreement B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter than average is verbally assertive with coworkers D. A client states that they did not get a job promotion because the boss did not like them - B A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? A. irritability B. increased urination C. vomiting D. facial flushing - A A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? A. A client who transfers their anger about their job onto their family and then apologizes B. A client who misses provider appointments because they say they are too busy C. A client who channels their energy into a new hobby following the loss of their job D. A client whose partner died 4 years ago sets a place for him at dinner each night - C A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? A. "We can expect the hospice nurse to provide support for us after our mother's death." B. A hospice nurse will come to the house each time our mother needs pain medication C. Now that my mother is receiving hospice services, we will not be able to get respite care D. Hospice care focuses on arranging treatment that will prolong our mother's life - A A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? A. Wear a surgical mask when providing client care B. Have visitors maintain a distance of 1.8m (6 feet) from the client C. Restrict fresh flowers from the clients room D. Assign the client to a private room with negative air pressure - D A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? A. Limit your fat intake for 72 hours before the test B. You will need to fast the night before the test C. We will collect a urine sample the day after testing D. A blood sample will be collected every 15 minutes during the test - B A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first? A. A 6month old infant who has croup and an O2 saturation of 92% on room air B. A 15 year old adolescent who is 2 hour postop following an open reduction and internal fixation of the left ankle and is requesting pain medication C. A 3 year old toddler who has gastroenteritis, moderate dehydration, and had 2 loose bowel movements over the past 24 hours D. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain. - D A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? A. Diarrhea B. Urinary retention C. Purulent discharge D. Abdominal bloating - D A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? A. Check the clients temperature B. Prepare to administer acetylcysteine to the client C. Place the client in the Trendelenburg position D. Check the client's oxygen saturation level - D A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A. An older adult client who reports constipation of 4 days B. A preschooler who has a skin rash C. An adolescent who has a closed fracture D. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? - D 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 nonweight- bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? A. Adjust the crutches for comfort as needed B. Use a three-point gait. C. Wear leather soled shoes D. Advance the affected leg first when walking upstairs - B 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 B. Great saphenous vein of the leg C. Dorsal plexus vein of the foot D. Basilic vein of the hand - A A nurse is planning to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP? A. Perform gastrostomy feedings through a clients established gastrostomy tube B. Administer glycerin suppository to a client who is constipated C. Provide instructions about client care to a family member over the telephone D. Teach a client how to measure their own blood pressure - A A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction? A. Dry the newborn immediately after birth B. Maintain an ambient room temp of 24 celcius C. Use a protective cover on the scale when weighing the infant D. Place the newborns bassinet away from outside windows - C A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following lab tests should the nurse review prior to adjusting the client's heparin? A. aPTT B. PT C. INR D. WBC count - A A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? A. Completion of the incident report B. Time the medication was given C. Reason for the medication error D. Notification of the pharmacist - B 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" 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." - D A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? A. Obtain capillary blood glucose level every 2 hours B. Check the neurovascular status of the client's lower extremities every hour C. Apply a cold pack to the client's ankle for 30 min every hour. D. Maintain the affected ankle elevated and immobilized - C A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? A. Diarrhea B. Frequent urination C. Excessive salivation D. Blurred vision - D A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? A. "Perhaps you think the ECT is dangerous, but I've seen it have good results" B. "You have the right to change your mind about this procedure at any time." C. "Everyone gets a little nervous about this procedure as the time for it approaches" D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you" - B A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? A. Select a 1 inch needle B. Use a 45 degree angle when inserting the needle C. Use the ventrogluteal site D. Pinch the skin up during injection - C A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching A. Check the functioning of oxygen equipment once each week B. Wear clothing made with cotton fabrics while oxygen is in use C. Apply petroleum-based lubricant to the nares as needed D. Store full oxygen tanks on their side - B A nurse is providing teaching to the guardians of a newborn about measures to prevent SIDS. Which of the following guardian statements indicates an understanding of the teaching? A. "I will not allow anyone to smoke near my baby." B. "I will place bumper pads in my baby's crib" C. "My baby's head should be placed on a pillow for sleeping" D. "My baby should sleep in a side-lying position" - A A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer? A. Nalbuphine B. Terbutaline C. Oxytocin D. Magnesium sulfate - C 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 ones. 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 for social services D. Encourage the client to continue with inpatient care - C A nurse is caring for a client who has a clogged percutaneous gastrostomy 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 - D 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 hours after the procedure C. Perform pulmonary function tests following the procedure D. Instruct the client to avoid coughing during the procedure - D A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions? A. "Droplet precautions should be initiated for client who tests positive for measles" B. "A client who requires airborne precautions should be placed in a negative pressure airflow room" C. "Airborne precautions should be initiated for a client who has Clostridium Difficile" D. "A client who is immunocompromised should be placed in a negative pressure airflow room" - B A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.) A.Broccoli B. Yogurt C. Pepperoni pizza D. Cream cheese E. Bologna sandwich - A B D A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect? A. Paradoxical chest movement B. Subcutaneous emphysema C. Acute confusion D. Distended neck veins - C A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? A. Maintain a flexible daily schedule for the client B. Use a reward system to modify the child's behavior C. Provide a variety of family members to care for the child D. Administer alprazolam as needed to reduce the child's anxiety - B A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuumassisted birth? A. Constipation B. Urinary urgency C. Cervical laceration D. Retained placenta - C 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 - D A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? (select all that apply) A. "You will give the medication every 4 hours" B. "Shake the medication bottle feel before each dose is given." C. "Store the medication in the refrigerator." D. "Report diarrhea to the provider immediately." E. "Discard the unused portion of medication after 21 days" - B C D A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? A. Instruct the client to void B. Position the client on their left side C. Insert an IV catheter D. Prepare the client for moderate (conscious) sedation - A A nurse is caring for a client who has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease? A. Initiate contract precautions for the client upon admission B. Restrict visitors from entering the client's room during hospitalization C. Wear a surgical mask while providing care for the client D. Have the client wear a surgical mask while being transported outside the room - D A nurse is caring for a client who has deep-vein thrombosis. Which of the following actions should the nurse take? A. Teach the client to massage the affected extremity B. Instruct the client to elevate the affected extremity when sitting C. Assess pulses proximal to the affected area D. Apply a cold compress to the affected extremity - B A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? A. Drainage system located above the clients chest wall B. Continuous bubbling in the water seal chamber C. Occlusive dressing on the insertion site D. Drainage of 125 mL/hr - C A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? A. The client is taking numerous deep, measured breaths B. The client is calmly telling their partner that "the staff here is so controlling" C. The client is sitting with their head in their hands and appears to be crying D. The client is pacing around the chair in which their partner is sitting - D A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Evaluate dietary intake for a client who has anorexia B. Measure the vital signs of a client who just returned from the PACU C. Arrange the lunch tray for a client who has a hip fracture D. Assess I&O for a client who is relieving dialysis - C A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? A. Decreased blood pressure B. Decreased hallucinations C. Decreased cholesterol D. Decreased esophageal reflux - B A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. Palpatation Inspection Percussion Auscultation - 1. Inspection 2. Auscultation 3. Percussion 4. Palpitation A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first? A. Determine the client's reading skills B. Instruct the client on the technique for esophageal speech C. Provide the client with an alphabet board D. Show the client how to use artificial larynx - A A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan? A. Encourage the client to take a cool sponge bath each morning B. Administer opioid analgesia C. Increase the client's dietary iron intake D. Restrict the client's intake of foods high in purines - C A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first? A. Document the client's refusal in the medication record B. Honor the client's decision to refuse the blood transfusion C. Explore the client's reasons for refusing the treatment D. Discuss the client's refusal with the provider - C A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? A. An older adult client who is anxious and attempting to pull out an IV line B. A middle adult client who is reporting nausea after receiving pain medication C. An older adult client who has kidney failure and returned from dialysis 4 hr ago D. A middle adult client who has a terminal illness and is requesting a visit from the chaplain - A A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? A. Calories B. Protein C. Potassium D. Fiber - D A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following method should the nurse include in the teaching? A. Delegate non-nursing tasks to ancillary staff B. Stock client rooms with extra supplies C. Assign dedicated equipment to each client's room D. Change continuous IV infusion tubing every 24 hours - A A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? A. Heart rate 136/min B. Nasal flaring C. Transient strabismus D. Overlapping of sutures - B A nurse is assessing a client who has a decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss? A. An increase in the intra-ocular pressure B. Deterioration of the macula C. Increased opacity of the lens D. Vitreous hemorrhage - C A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge? A. A client who has cellulitis and is receiving oral antibiotics every 8 hr B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C. A mother and their newborn 12 hr postdelivery D. A client who has lower extremity weakness and is newly admitted for observation - A A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take? A. Contact the facility's ethics committee B. Obtain consent from the client's employer C. Limit care to comfort measures D. Proceed with provision of medical care - D A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include the plan? (see exhibit)History and physical:8 year old male admitted with cystic fibrosisReports shortness of breathWheezing throughout lung fieldsProductive cough with thick sputum Graphic Record:Heart rate 108/minRespiratory rate 26/minTemperature 37.2 (98.9)Blood pressure 100/62Oxygen saturation 92%Diagnostic results:Sputum culture: Burkholderia cepacia A. Initiate droplet isolation precautions B. Keep the child on NPO status for 12 hours C. Maintain the child on bed rest for 24 hours D. Administer high-dose antibiotic therapy - D A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching? A. "Expect to have blurred vision while taking this medication" B. "Notify your provider if you experience increased thirst" C. "You might be unable to have an orgasm while taking this medication" D. "You should take this medication on an empty stomach" - B A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mmHg, and HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory Alkalosis B. Metabolic Alkalosis C. Respiratory Acidosis D. Metabolic Acidosis - C A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching? A. "I can designate my partner as my health care surrogate" B. "I am only 40 years old, so I don't need to worry about this yet" C. "I will need a lawyer's help to draw up the documents" D. "I understand that my family can alter my advance directives if I become incapacitated" - A A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? A. "I would like to talk to you about the unit policies regarding break time." B. "If you continue to take a long lunch break, I will have to report this to the nurse manager" C. "Have you thought about how your extended lunch breaks affect the other members of our team?" D. "Did you inform the other members of your team about when you left and returned from break?" - A A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? A. Organizing the work environment B. Delegating assigned tasks appropriately C. Making a list of activities to complete D. Rewarding yourself for accomplishing goals - C A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? A. Tinnitus B. Cough C. Polyuria D. Blurred vision - B A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? A. A client whose family requests hospital based hospice care B. A client who requires transfer to a skilled care facility C. A client who qualifies for telehealth for pacemaker diagnostics D. A client whose caregiver requests adult day care services - D A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect? A. Fever B. Shortened femoral neck C. Edema D. Dark brown urine - C A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? A. Encourage oral fluids B. Apply topical calamine lotion C. Administer acetaminophen as an antipyretic D. Initiate transmission based precautions - D A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? A. Strict adherence to routines B. Difficulty paying attention to tasks C. Disobedience to authority figures D. Excessive anxiety when separated from parents - A A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make? A. "I understand your hesitation, but I'm very proud of you for making the right decision" B. "Organ donation from a first degree relative is your brother's best chance of survival" C. "You're afraid that your other kidney will fail at some point after the organ donation" D. "I know this process won't be easy, but you should focus on saving your brother's life" - C A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? A. Check the client's blood type and crossmatch it against the providers orders B. Ask the client to state their blood type prior to beginning blood administration C. Compare information on the blood product to the informed consent form D. Verify the client and blood product information with another licensed nurse. - D A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? A. The last time the provider evaluated the client B. The client's most recent ventilator settings C. The time of the client's last dose of pain medication D. The frequency in which the client presses the call buttom - C A nurse is reviewing the lab report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following lab values should the nurse report to the provider? A. Platelets 268,000/mm3 B. Calcium 9.2 mg/dL C. WBC 5,200/mm3 D. Sodium 148 mEq/L - D