ATI Capstone Care of Children Pre-Assessment Quiz:
Updated A+ Guide Solution
/. A nurse is assessing a client who has a pressure ulcer. The nurse should recognize
which of the following findings is a manifestation of a stage 3 pressure ulcer? - Answer-
Necrotic subcutaneous tissue
Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with
necrotic subcutaneous tissue.
/.A nurse is caring for a client who has a tracheostomy. Select the 3 findings that require
immediate follow-up. SATA
BP on day 2
O2 Sat on day 2
Tracheal secretions
Breath sounds day 1
RR day 2 - Answer-O2 sat on day 2
Tracheal secretions
RR day 2
The client's O2sat is below the expected reference range indicating hypoxia. Thick
yellow secretions are a manifestation of a respiratory infection. The client's RR is
greater than the expected reference range indicating hypoxia.
/.A nurse is caring for a client who is postoperative following abdominal surgery. The
surgeon initially prescribes a clear liquid diet. Which of the following items should the
nurse include on the client's lunch tray? - Answer-Cranberry juice
Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice
and grape juice.
/.A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The
nurse should anticipate that the client will require teaching about which of the following
medications? - Answer-Acetaminophen
According to the American Pain Society, acetaminophen is the primary drug of choice
for treating osteoarthritis. The provider would likely begin with this medication.
/.A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage
kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I
decided to come today, but I am not sure if I will need to come back again this week. I
am feeling much better since my discharge from the hospital and I think my kidneys are
working again." The nurse should identify that this client is demonstrating which of the
following Kubler-Ross stages of grieving? - Answer-Denial
, During the denial stage of Kubler-Ross' stages of grieving, the client acts as though
nothing has happened and might refuse to believe or understand that a loss has
occured.
/.A nurse is caring for a client who states, "I have to get out of this hospital! They have
found my address and are coming for my family!" The nurse responds, "Don't worry, no
one will harm your family." Which of the following types of communication breakdown
does this response represent? - Answer-Offering false reassurance
Offering false reassurance discourages further communication because there are no
facts to support it. A better response would be to clarify mispercetptions.
/.A nurse is caring for a client who experienced a lacerated spleen and has been on
bedrest for several days. The nurse auscultates decreased breath sounds in the lower
lobes of both lungs. The nurse should realize that this finding is most likely an indication
of which of the following conditions? - Answer-Atelectasis
Atelectasis is the collapse of part or all of a lung by blockage of the air passages
(bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in
position, ineffective coughing, and underlying lung disease are risk factors for the
development of atelectasis.
/.A nurse is preparing to administer ophthalmic solution to a client. Which of the
following actions should the nurse take? - Answer-Hold the ophthalmic solution 2 cm
(3/4 in) above the lower conjunctival sac
The nurse should hold the bottle of ophthalmic solution 1 to 2 cm (1/2 to 3/4 in) above
the lower conjunctival sac.
/.A nurse is caring for a client who has cancer and is receiving palliative care. Which of
the following statements by the client indicates they understand this type of treatment? -
Answer-"I am hoping this will limit my discomfort."
Clients receiving palliative care are aware that the outcome is to prevent suffering and
provide the best possible quality of life.
/.A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25
in) at the point of pressure. Which of the following notations should the nurse use to
document the severity of the client's edema? - Answer-3+
The nurse should document pitting edema of 5 to 7 mm as 3+.
/.A nurse is reviewing the medical record for a client who has a health care-associated
infection (HAI). The nurse should identify which of the following findings as a risk factor
for acquiring an HAI? - Answer-The client is 71 years old.
Updated A+ Guide Solution
/. A nurse is assessing a client who has a pressure ulcer. The nurse should recognize
which of the following findings is a manifestation of a stage 3 pressure ulcer? - Answer-
Necrotic subcutaneous tissue
Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with
necrotic subcutaneous tissue.
/.A nurse is caring for a client who has a tracheostomy. Select the 3 findings that require
immediate follow-up. SATA
BP on day 2
O2 Sat on day 2
Tracheal secretions
Breath sounds day 1
RR day 2 - Answer-O2 sat on day 2
Tracheal secretions
RR day 2
The client's O2sat is below the expected reference range indicating hypoxia. Thick
yellow secretions are a manifestation of a respiratory infection. The client's RR is
greater than the expected reference range indicating hypoxia.
/.A nurse is caring for a client who is postoperative following abdominal surgery. The
surgeon initially prescribes a clear liquid diet. Which of the following items should the
nurse include on the client's lunch tray? - Answer-Cranberry juice
Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice
and grape juice.
/.A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The
nurse should anticipate that the client will require teaching about which of the following
medications? - Answer-Acetaminophen
According to the American Pain Society, acetaminophen is the primary drug of choice
for treating osteoarthritis. The provider would likely begin with this medication.
/.A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage
kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I
decided to come today, but I am not sure if I will need to come back again this week. I
am feeling much better since my discharge from the hospital and I think my kidneys are
working again." The nurse should identify that this client is demonstrating which of the
following Kubler-Ross stages of grieving? - Answer-Denial
, During the denial stage of Kubler-Ross' stages of grieving, the client acts as though
nothing has happened and might refuse to believe or understand that a loss has
occured.
/.A nurse is caring for a client who states, "I have to get out of this hospital! They have
found my address and are coming for my family!" The nurse responds, "Don't worry, no
one will harm your family." Which of the following types of communication breakdown
does this response represent? - Answer-Offering false reassurance
Offering false reassurance discourages further communication because there are no
facts to support it. A better response would be to clarify mispercetptions.
/.A nurse is caring for a client who experienced a lacerated spleen and has been on
bedrest for several days. The nurse auscultates decreased breath sounds in the lower
lobes of both lungs. The nurse should realize that this finding is most likely an indication
of which of the following conditions? - Answer-Atelectasis
Atelectasis is the collapse of part or all of a lung by blockage of the air passages
(bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in
position, ineffective coughing, and underlying lung disease are risk factors for the
development of atelectasis.
/.A nurse is preparing to administer ophthalmic solution to a client. Which of the
following actions should the nurse take? - Answer-Hold the ophthalmic solution 2 cm
(3/4 in) above the lower conjunctival sac
The nurse should hold the bottle of ophthalmic solution 1 to 2 cm (1/2 to 3/4 in) above
the lower conjunctival sac.
/.A nurse is caring for a client who has cancer and is receiving palliative care. Which of
the following statements by the client indicates they understand this type of treatment? -
Answer-"I am hoping this will limit my discomfort."
Clients receiving palliative care are aware that the outcome is to prevent suffering and
provide the best possible quality of life.
/.A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25
in) at the point of pressure. Which of the following notations should the nurse use to
document the severity of the client's edema? - Answer-3+
The nurse should document pitting edema of 5 to 7 mm as 3+.
/.A nurse is reviewing the medical record for a client who has a health care-associated
infection (HAI). The nurse should identify which of the following findings as a risk factor
for acquiring an HAI? - Answer-The client is 71 years old.
