RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT PRACTICE TEST B
1 A nurse is assessing a client who received 2 units of packed RBCs 48 hours ago. W
... [Show More] hich of the following findings should indicate to the nurse that the therapy has been effective?
Hemoglobin 14.9 g/dl
The nurse should identify that packed RBCs are administered to clients who have a decreased level of hemoglobin or hematocrit. This hemoglobin level is within the expected reference range of 14 to 18 g/dl for males and 12 to 16 g/dl for females,
2 .A nurse working in a n emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?
A middle adult client who has unstable vital signs.
Using the stable versus unstable approach to client care, the nurse should recommend priority treatment for the client who has unstable vital signs because this client requires
3. A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to the CNA?
Measure the client’s daily weight
It is within the CNAs range of function to measure a client’s daily weight, so the nurse should delegate this task to them.
4. A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198lb. What is the amount in grams the nurse should administer?
18 g
5. A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint?
In the correct image, the adolescent is abduction the hip joint by moving the leg away from the midline of the body.
6. A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?
Tremors
2
Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia.
7. A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following findings should the nurse expect?
Nuchal rigidity
This is a manifestation of bacterial meningitis.
8. A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse take?
Auscultate the apical pulse at least 1 min.
The nurse should auscultate the apical pulse to obtain an accurate assessment of heart rate and rhythm. Auscultation of a newborn’s heart sounds can be difficult because of the rapid rate and the transmission of respiratory sounds.
9. 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?
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.
10. A nurse in the ED is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?
The child exhibits discomfort while walking.
The nurse should identify this finding as a potential indication of child sexual abuse.
11. A nurse is preparing to teach about dietary management to a client who has Crohn’s disease and an entero enteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?
Fiber
The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and
12. A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
Turn off the CPM machine during mealtime. This promotes client comfort and dietary intake.
3
13. 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 the client?
Radial vein of the inner arm.
This site will have adequate subcutaneous tissue
14. A nurse is developing a client education program a bout osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?
Sedentary lifestyle.
This is a risk factor for osteoporosis. The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels.
15. A nurse in an ED 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?
Initiate transmission-based precautions
When using the urgent versus nonurgent approach to client care, the nurse should determine that the priority action is to initiate transmission-based precautions for the child. The child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection.
16. 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?
Change the position of the client.
When providing client care, the nurse should use the least restrictive intervention first. Therefore, the nurse should reposition the client to remove any kinks in the tube, which can lead to clogging. If this method is unsuccessful, the nurse should attempt to flush or aspirate the client’s tube to remove the clog.
17. A home health care nurse is developing a teaching plan for a client who has a new ileostomy.
Which of the following instructions should the nurse include?
Empty the appliance when it is one-third to one-half full.
The ileostomy pouch should be emptied when it is one-third to one-half full to prevent stool leakage and skin irritation.
4
18. A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 yr ago. Which of the following lab values should the nurse report to the provider?
Sodium 148 mEq/L
The nurse should report this sodium level because it is a bove the expected reference range of 136 to 145 mEq/L, indicating hypernatremia. Clients who have kidney disease often retain sodium and require sodium-restricted diets.
19. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to a
CNA?
Arrange the lunch tray for a client who has a hip fracture.
Assisting a client with meals is within the range of function of the CNA.
20. A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?
Instruct the client to void.
The nurse should instruct the client to void prior to the procedure because an empty bladder decreases the risk of a bladder puncture and minimizes the client’s discomfort during the procedure.
21. A nurse has received change of shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
A client who is receiving an MAOI and is requesting a cheeseburger for dinner. This client’s food selection contains tyramine. Clients prescribed an MAOI must restrict the
22. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?
Allow for frequent rest periods throughout the day.
The nurse should encourage the client to balance rest with exercise to maintain muscle strength, joint function, and range of motion.
23. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased urinary output. Which of the following action should the nurse take?
5
Irrigate the catheter with 0.9% sodium chloride irrigation.
Decreased urine output and bladder spasms indicate internal obstruction of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does not clear.
24. A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
pH 7.31
Respiratory acidosis is an expected finding for a client who has COPD. The expected reference range of pH is 7.35-7.45. A pH level of less than 7.35 indicates acidosis. For a client who has COPD, a decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45 mm Hg, indicating respiratory acidosis.
25. 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?
Abdominal bloating
The nurse should include the presence of abdominal bloating as an early manifestation of ovarian cancer. Other manifestations include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency. [Show Less]
