ATI Capstone Post Assessment Exam with 41 Questions and Answers 2023
ATI Capstone Post Assessments/41 Questions And
Answers.
A pregnant client has a
... [Show More] history of giving birth to one set of twin boys, one
term girl and 2 early spontaneous abortions. What is her gravida and para? -
Correct Answer -She is gravida 4, Para 2
Gravida indicates the number of times the mother has been pregnant,
regardless of whether these pregnancies were carried to term. A current
pregnancy, if any, is included in this count.
Para indicates the number of >20 wks births (including viable and non-viable
i.e. stillbirths). Pregnancies consisting of multiples, such as twins or triplets,
count as ONE birth for the purpose of this notation.
A nurse is providing care for an uncircumcised male newborn and his mother.
What information should be provided during discharge regarding bathing of
the penile area of the newborn male? - Correct Answer -To cleanse an
uncircumcised penis, wash with soap and water and rinse the penis. The
foreskin should not be forced back or constriction may result.
The 24-year-old client inquires about use of the diaphragm for birth control.
What five (5) instructions would be provided by the nurse to explain use of
the diaphragm? - Correct Answer -●A client should be properly fitted with a
diaphragm by a provider.
●Replaced every 2 years and refitted for a 20% weight fluctuation, after
abdominal or pelvic surgery, and after every pregnancy.
●Requires proper insertion and removal. Prior to coitus, the diaphragm is
inserted vaginally over the cervix with spermicidal jelly or cream that is
applied to the cervical side of the dome and around the rim. The diaphragm
can be inserted up to 6 hr before intercourse and must stay in place 6 hr
after intercourse but for no more than 24 hr.
●Spermicide must be reapplied with each act of coitus.
●A client should empty her bladder prior to insertion of the diaphragm.
●Diaphragm should be washed with mild soap and warm water after each
use.
A nurse is providing teaching about fibrocystic breast tissue with a client.
What information will the nurse share with the client about diagnostics used
to confirm the diagnosis? - Correct Answer -Diagnostics for fibrocystic breast
tissue include breast ultrasound and fine-needle aspiration.
A client asks the nurse how often she should get a Papanicolaou (Pap) test.
What is the correct response by the nurse to the client? - Correct Answer -21:
All women begin screening for cervical cancer
21-29: Pap test every 3 years; HPV unnecessary unless needed following an
abnormalPap test
30-65: Pap and HPV every 5 years
Older than 65: May discontinue testing if regular screenings have been
negative; If diagnosed with cervical precancer, continue to screen
List three (3) actions by the nurse should take during the assessment and
data collection steps. - Correct Answer -Recognize patterns or trends.
Compare the data with expected standards or reference ranges.
Arrive at conclusions to guide nursing care.
When witnessing an informed consent the nurse must ensure that the
provider gives the client the necessary procedural information. Identify
information the provider should disclose to the client to obtain an informed
consent. What is the role of the nurse in this process? - Correct Answer -The
Provider obtains the informed consent. To do so, the provider must give the
client:
· The purpose of the procedure· A complete description of the procedure.
· A description of the professional who will perform and participate in the
procedure.
· A description of the potential harm, pain or discomfort that might occur.
· Options for other treatments.
· The option to refuse treatment and the consequences of doing so. The
nurse must notify the provider if the client has more questions or appears
not to understand any of the information. The provider is then responsible for
giving clarification.
Discuss passive and active immunity. - Correct Answer -Passive: Antibodies
are produced by an external source. Temporary immunity that does not have
memory of past exposures. Intact skin, the body's first line of defense.
Mucous membranes, secretions, enzymes, phagocytic cells, and protective
proteins. Inflammatory response with phagocytic cells, the complement
system, and interferons to localize the invasion and prevent its spreadActive:
Antibodies are produced in response to an antigen. Requires time to react to
antigens. Provides permanent immunity. Involves B- and T-lymphocytes.
Produces specific antibodies against specific antigens (immunoglobulins [IgA,
IgD, IgE, IgG, IgM])
List at least three (3) priority considerations when performing a sterile
dressing change. - Correct Answer --Prolonged exposure to airborne microorganisms can make sterile items non-sterile.
-Avoid coughing, sneezing, and talking directly over a sterile field.
-Air movement should be controlled by special ventilation.
-Only sterile items may be in a sterile field.
-The outer wrappings and 1-inch edges of packaging that contains sterile
items are not sterile.
-The inner surface of the sterile drape or kit, except for that 1-inch border
around the edges, is the sterile field to which additional sterile items may be
added.
-To position the field on the table surface, it is acceptable to grasp the 1-inch
border before donning sterile gloves.
-Any object that comes into contact with the 1-inch border must be
discarded.
-Touch sterile materials only with sterile gloves.
-Any object held below the waist or above the chest is considered
contaminated.
-Sterile materials may touch other sterile surfaces or materials; however,
contact with non-sterile materials at any time renders a sterile area
contaminated, no matter how short the contact.
-Microbes can move by gravity from a non-sterile item to a sterile item: Do
not reach across or above a sterile field.
-Do not turn your back on a sterile field.
-Hold items to be added to a sterile field at a minimum of 6 inches above the
field.
-Any sterile, non-waterproof wrapper that comes in contact with moisture
becomes non-sterile by a wicking action that allows microbes to travel
rapidly from a non-sterile surface to the sterile surface.
-Keep all surfaces dry.
-Discard any sterile packages that become wet.
A nurse is caring for an elderly client with constipation. What are three (3)
complications to monitor for during care of this client? - Correct Answer
-Complications of constipation include:Fecal impaction.Development of
hemorrhoids or rectal fissures.Bradycardia, hypotension, and syncope
associated with the Valsalva maneuver (occurs with straining/bearing down).
A nurse is caring for a client who has refused his morning medications. How
should the nurse respond to the client? - Correct Answer -The nurse should
recognize the client's right to refuse any medication. The nurse should
explain the consequences of not taking the prescribed medications and
encourage the client to take the medications as prescribed by the provider.
The nurse is caring for a client recently diagnosed with depression. The client
was prescribed an SSRI antidepressant. What assessment findings should be
reported to the provider for a client taking this medication? - Correct Answer
-Potential complication/adverse effects to be reported to the provider:
Sexual dysfunction
Insomnia, agitation, anxiety
Changes in weight
Withdrawal syndrome - headache, nausea, visual disturbance, anxiety,
dizziness and tremors
Hyponatremia
Rash
Sleepiness, lightheadedness, faintness
Gastrointestinal bleeding
Bruxism
Serotonin syndrome (Can begin 2-72 hours after starting treatment and can
be lethal)
Mental confusion, delirium
Fever, tachycardia, elevated blood pressure
Abdominal pain, diarrhea
Irritability, mood swings, agitation, anxiety, restlessness
Incoordination, hyperreflexia, diaphoresis, tremors, muscle spasms
Cardiovascular shock, seizures, death
A client is prescribed a protease inhibitor—ritonavir. Identify three (3) nursing
considerations when administering a protease inhibitor. - Correct Answer
-Instruct client to report all other the counter medications; except for
indinavir, take protease inhibitors with food to increase absorption;
administer with another antiretroviral; advise barrier form of contraception;
advise diet high in calcium and vitamin D.
A nurse is caring for a client who has a new prescription for alosetron. What
are the expected therapeutic effects of this medication? - Correct Answer
-Effectiveness of alosetron can be evidenced by relief of diarrhea, and
decrease in urgency and frequency of defecation.
A client has been prescribed oxybutynin for treatment of overactive bladder
and has been experiencing anticholinergic side effects. List two (2) actions
the client will take to prevent adverse effects of the medication therapy. -
Correct Answer -Adverse Effects of oxybutynin:
Constipation, dry mouth, blurred vision, photophobia, dry eyes, CNS effects
(hallucinations, confusion, insomnia and nervousness)
Client Actions:
Increase dietary fiber; Consume 2 to 3 L/day of fluid from beverage; Avoid
hazardous activities if my vision is impaired
A nurse has provided education to a client with hypothyroidism who has a
new prescription for levothyroxine. What statements by the client would
indicate they understand the instructions? - Correct Answer -The following
client statements indicate understanding of the nurse education concerning
their levothyroxine prescription: take the medication daily on an empty
stomach 30 to 60 min before breakfast; will verbalize the importance of
lifelong replacement (even after improvement of symptoms) and will not to
discontinue the medication without checking with the provider; will check
with the provider before switching to another brand of levothyroxine; will
monitor and report signs of cardiac excitability (angina, chest pain,
palpitations, dysrhythmias); and will have T4 and TSH levels drawn as
directed by their provider.
A nurse is administering vancomycin to a client who develops an infusion
reaction sometimes referred to as red man syndrome. What action by the
nurse could have prevented this reaction? - Correct Answer -Infusion
reactions (rashes, flushing, tachycardia, and hypotension, sometimes called
"red man syndrome") is an adverse effect of vancomycin administration that
could be prevented by administering vancomycin slowly over 60 min.
Protamine sulfate is the antidote for heparin overdose. What are two (2)
nursing considerations for the administration of protamine sulfate? - Correct
Answer -Protamine should be administered slowly IV, no faster than 20
mg/min or 50 mg in 10 min. Do not exceed 100 mg in a 2-hr period.
A nurse is providing teaching to a client who is prescribed methotrexate for
chemotherapy treatment. What should the nurse include in the teaching for
this medication? - Correct Answer -Instruct clients to take the medication on
an empty stomach.
Advise clients to protect the skin from sunlight.Advise female clients to use
birth control during and for 6 months after completing treatment (Pregnancy
Risk Category X).
A nurse is providing discharge teaching to a client prescribed ketorolac, what
adverse effects should the client report to the provider? - Correct Answer
-Gastrointestinal discomfort - Dyspepsia, Abdominal pain, heartburn, nausea
Impaired Kidney function - Decreased urine output, weight gain from fluid
retention, Increased BUN, and creatinine levels
Increased risk for bleeding - hematomas, bleeding gums, blood in vomit or
stool, decreased Hematocrit and Hemoglobin
Ketorolac is contraindicated in clients who have advanced kidney disease.
Use should be no longer than 5 days due to the risk of kidney injury.
Ketorolac should not be used concurrently with other NSAIDS.
A nurse is caring for a client following a bone marrow biopsy. What
information should the nurse include in the discharge teaching? - Correct
Answer -Teach the client to report excessive bleeding and evidence of
infection to the provider.Teach the client to check the biopsy site daily. Keep
the dressing clean, dry, and intact.If sutures are in place, remind the client to
return in 7 to 10 days to have them removed.
Define the following types of urinary incontinence: stress, functional, and
total. - Correct Answer -There are three major types of urinary incontinence:
Stress - The loss of small amounts of urine when laughing, sneezing, or lifting
primarily due to weak pelvic muscles, urethra, or surrounding tissues.
Functional - The inability to get to the bathroom to urinate due to physical,
cognitive, or social impairment.
Total - The unpredictable, involuntary loss of urine that does not generally
respond to treatment.
A nurse is caring for a client with colorectal cancer who is scheduled for a
colectomy. What pre and post-operative teaching should be provided? -
Correct Answer -Preoperative
Educate the client regarding preoperative diet (clear liquids several days
prior to surgery).
Instruct the client to complete bowel prep with cathartics as prescribed.
Inform the client of the administration of antibiotics (neomycin,
metronidazole) to eradicate intestinal flora.Postoperative
Educate the client regarding the care of the incision, activity limits, and
ostomy care, if applicable.
The nurse is caring for a client with suspected bacterial meningitis. What is a
priority action for the nurse to initiate? - Correct Answer -Isolate the client
and maintain droplet precautions per facility protocol.
A child was sent home from school with head lice. The child's mother has
called the help line nurse for guidance. What are three (3) measures the
nurse will inform the mother about to address the infestation of pediculosis
capitis? - Correct Answer -Interventions for Infestation
Shampoos containing 1% permethrin as prescribed.
Remove nits with a nit comb, repeat in 7 days after shampoo treatment.
Wash cloting, bedding in hot water with detergent.
Difficult cases: use malathion 0.5% in isopropanol.Discourage sharing of
personal items.
Teach the parents to boil hair accessories in lice-killing products for 1 hour.
Launder potentially infected clothing and bedding.
The nurse is using the FLACC pain scale. What is the recommended age
range whe using this pain scale? - Correct Answer -FLACC is used for ages 2
months to 7 years
FACE (F)
0: Smile or no expression
1: Occasional frown or grimace, withdrawn
2: Frequent or constant frown, clenched jaw, quivering chin
LEGS (L)
0: Relaxed or normal position
1: Uneasy, restless, tense
2: Kicking or legs drawn up
ACTIVITY (A)
0: Lying quietly, moves easily, normal position
1: Squirming, shifting, tense
2: Arched, ridged, or jerking
CRY (C)
0: No cry
1: moans or whimpers, occasional complaints
2: Crying, screaming, sobbing, frequent complaints
CONSOLABILITY (C)
0: Content or relaxed
1: Reassured by occasional touching or hugging. Able to distract
2: Difficult to console or comfort
Give an example of how a nurse exhibits fidelity in client care. - Correct
Answer -Fidelity is loyalty and faithfulness to the client and to one's duty as a
nurse. Example: A client asks a nurse to be present when they talk to their
guardian for the first time in a year. The nurse remains with the client during
this interaction.
A client in a mental health setting has the same civil rights as any other
citizen. List five (5) rights that are included. - Correct Answer -Clients who
have a mental health disorder diagnosis or who are receiving acute care for
mental health disorder are guaranteed the same civil rights as any other
citizen. These include the following.
The right to humane treatment and care (medical and dental care)
The right to vote
The rights related to granting, forfeiture, or denial of a driver's license
The right to due process of law, including the right to press legal charges
against another person
Clients also have various specific rights, including the following
Informed consent and the right to refuse treatment
Confidentiality
A written plan of care/treatment that includes discharge follow-up, as well as
participation in the care plan and review of that plan
Communication with people outside the mental health facility, including
family members, attorneys, and other health care professionals
Provision of adequate interpretive services if needed
Care provided with respect, dignity, and without discrimination
Freedom from harm related to physical or pharmacological restraint,
seclusion, and any physical or mental abuse or neglect
A psychiatric advance directive that includes the client's treatment
preferences in the event that an involuntary admission is necessary
Provision of care with the least restrictive interventions necessary to meet
the client's needs without allowing them to be a threat to themselves or
others
Which of the following clients would be the priority to assess first?
A client diagnosed with schizophrenia that is exhibiting negative symptoms.
A client with substance-induced psychotic disorder related to substance
intoxication.
A client who is suffering from delusions of grandeur.
A client suffering from olfactory hallucinations. - Correct Answer -A client with
substance-induced psychotic disorder related to substance
intoxication.Substance-induced psychotic disorder: The client experiences
psychosis due to substance intoxication or withdrawal However, the
psychotic manifestations are more severe than typically expected.
What are priority actions for a client who is threatening self-harm? - Correct
Answer -Setting limits for the client
Tell the client calmly and directly what they must do in a particular situation,
such as, "I need you to stop yelling and walk with me to the day room where
we can talk."
Use physical activity, such as walking, to deescalate anger and behaviors
Inform the client of the consequences of their behavior, such as loss of
privileges
Plan for four to six staff members to be available and in sight of the client as
a "show of force" is appropriate.
The nurse is caring for an older adult client experiencing sleep disturbance.
Identify three (3) teaching points related to methods to alleviate sleep
disturbances. - Correct Answer -Monitor neurologic status
Implement measures to promote sleep.
Teach the client relaxation techniques
Arrange the sleep environment for comfort.
Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
Limit fluids 2 to 4 hr before bedtime.
Engage in muscle relaxation if anxious or stressed.Provide a room with a low
level of visual and auditory stimuli.
A nurse is completing a physical assessment on a child. What are three (3)
potential signs of neglect? - Correct Answer -Neglect, which includes the
failure to provide:
Physical care, such as feeding.
Emotional care, such as interacting with a child, or stimulation necessary for
a child to develop normally.
An education for a child, such as enrolling a young child in school.
Necessary health or dental care.
A nurse is caring for a client in the manic phase of bipolar disorder. Identify
three (3) clinical manifestations associated with this phase of the bipolar
disorder. - Correct Answer -Bipolar - Manic Phase:
Labile mood with euphoria
Agitation and irritability
Restlessness
Dislike of interference and intolerance of criticism
Increase in talking and activity
Flight of ideas - rapid, continuous speech with sudden and frequent topic
change
Grandiose view of self and abilities (grandiosity)
Impulsivity - spending money, giving away money or possessions
Demanding and manipulative behavior
Distractibility and decreased attention span
Poor judgment
Attention-seeking behavior - flashy dress and makeup, inappropriate
behavior
Impairment in social and occupational functioning
Decreased sleep
Neglect of ADLs, including nutrition and hydration
Possible presence of delusions and hallucinations
Denial of illness
Describe the manifestations that are associated with obsessive-compulsive
disorders. - Correct Answer -Obsessive Compulsive Disorder (OCD): the client
has intrusive thoughts of unrealistic obsessions and tries to control these
thoughts with compulsive behaviors such as repetitive cleaning of a
particular object or washing of hands. Obsessions or compulsions are timeconsuming and result in impaired social and occupational functioning. This
disorder affects women more than men, and there is thought to be a genetic
and neurobiological link.
A nurse is caring for a client with panic disorder. Discuss nursing care of this
client. - Correct Answer -Provide a structured interview to keep the client
focused on the present.● Assess for comorbid condition of substance use
disorder. ● Provide safety and comfort to the client during the crisis period of
these disorders, as clients in severe- to panic-level anxiety are unable to
problem solve and focus. Clients experiencing panic-level anxiety benefit
from a calm, quiet environment. The nurse should:● Remain with the client
during the worst of the anxiety to provide reassurance. ● Perform a suicide
risk assessment.● Provide a safe environment for other clients and staff.●
Provide milieu therapy that employs the following: A structured environment
for physical safety and predictability. Monitoring for, and protection from,
self-harm or suicide. Daily activities that encourage the client to share and
be cooperative. Use of therapeutic communication skills (open-ended
questions) to help the client express feelings of anxiety, and to validate and
acknowledge those feelings. Client participation in decision making regarding
care.● Use relaxation techniques with the client as needed for relief of pain,
muscle tension, and feelings of anxiety.● Instill hope for positive outcomes
(but avoid false reassurance).● Enhance client self-esteem by encouraging
positive statements and discussing past achievements.● Assist the client to
identify defense mechanisms that interfere with recovery.● Postpone health
teaching until after acute anxiety subsides. Clients experiencing a panic
attack or severe anxiety are unable to concentrate or learn.● Identify
counseling, group therapy, and other community resources for clients who
have anxiety.
A nurse is caring for a client who is exhibiting displacement as a defense
mechanism. Define displacement. Provide an example of this defense
mechanism. - Correct Answer -Definition: Displacement is the shifting
feelings related to an object, person, or situation to another less threatening
object, person, or situation Example: A person who is angry about losing his
job destroys his child's favorite toy.
An ethical dilemma regarding sustaining life is being examined. What would
be some appropriate resources for the nurse to use to help review and
address ethical dilemmas? - Correct Answer -A dilemma is a choice between
two unpleasant ethically troubling alternatives. This includes confidentiality,
patient rights, and issues of death and dying. The nurse must use ethical and
legal guidelines to make decision about moral actions when providing care in
these and many other situations.
Identify whether the issue is indeed an ethical dilemma. State the ethical
dilemma including all surrounding issues and individuals involved. List and
analyze all possible options for resolving the dilemma and review
implications of each option.Select the option that is in concert with the
ethical principle applicable to this situation, the decision maker's values and
beliefs, and the profession's values set forth for client care. Justify why that
one option was selected. Apply this decision to the dilemma and evaluate the
outcomes.
The charge nurse is tasked with performing a peer review for one of her
colleagues. Describe what this process should include. - Correct Answer -Peer
review is the evaluation of a colleague's practice by another peer. Peer
review should: Begin with an orientation of staff to the peer review process,
their professional responsibility in regard to promoting growth of colleagues,
and the disposition of data collected. Focus on the peer's performance in
relation to the job description or an appraisal tool that is based on
institutional standards. Be shared with the peer and usually the manager. Be
only part of the data used when completing a staff member's performance
appraisal.
After signing an informed consent, the client states, "I can't go through with
this, I will not have the surgery!" What is the nurse's responsibility in this
situation? - Correct Answer -As advocates, nurses must ensure that clients
are informed of their rights including the right to refuse treatment and have
adequate information on which to base health care decisions. The nurse
should verify the patient is competent to refuse treatment, ensure the client
understands the information, contact the provider to discuss risks of refusal
with client.
A nurse is caring for a client newly diagnosed with pertussis. What is one (1)
intervention the nurse will incorporate into the plan of care? - Correct Answer
-Ensure disease is reported, if appropriate.
Provide education related to transmission, treatment, complications.
Ensure client is placed in appropriate form of isolation.
Ensure client is receiving appropriate treatment for diagnosis.
Monitor for further cases/outbreaks.
Develop control and prevention plans.
An occupational health nurse is working with their employer to identify and
address physical agents present in the current work environment. What are
two (2) examples of physical agents the nurse needs to be aware of? -
Correct Answer -Noise
Vibration
Radiation
Temperature extremes
Exposure to hazardous chemicals
Electromagnetic fields
ElectricityPhysical agents are sources that may cause injury/disease. [Show Less]