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RN ATI CAPSTONE PROCTORED
COMPREHENSIVE ASSESSMENT
ACTUAL EXAM QUESTIONS WITH
DETAILED VERIFIED ANSWERS LATEST
VERSION
"Caring for a school age child taking valporic acid. Diagnostic tests - CORRECT ANSWER=> Serum liver enzyme levels" "Inpatient mental health unit is monitoring a visit between client with aggressive behavior and the client's partner - CORRECT ANSWER=> The client is pacing around the chair in which his partner is sitting." "Home health nurse evaluating a school age child with cystic fibrosis initiates a request for high frequency chest compression vest - CORRECT ANSWER=> My child has only a small amount of mucus after percussion therapy" "Planning care for a client with left sided weakness following a stroke - CORRECT ANSWER=> Support the client's left arm on a pillow while sitting" "caring for a client who has schizophrenia who recently started risperidone - CORRECT ANSWER=> Implement fall precautions for the client" "Caring for a child with a fever and fluid filled vesicles on trunk and extremities. Identify priority
- CORRECT ANSWER=> Initiate transmission based precautions" "Assessing client for compartment syndrome expected findings - CORRECT ANSWER=> Edema"
"Just received change of shift report on 4 clients. Which should the nurse assess first - CORRECT ANSWER=> A client who is postop with abdominal distention and no bowel sounds" "Assessing a client after administering epinephrine for anaphylactic reactions. Identify adverse effect of this med - CORRECT ANSWER=> Report of Chest pain" "Provide teaching to client 24 wks gestation scheduled for glucose tolerance test - CORRECT ANSWER=> You will need to fast the night before the test." "Assessing older adult client with pneumonia - CORRECT ANSWER=> acute confusion" "Teaching for client about right to confidentiality - CORRECT ANSWER=> You can provide a list of family members who can receive information about the diagnosis." "Caring for a client reporting nausea and vomiting the past 2 days - CORRECT ANSWER=> Urine specific gravity 1.052" "Caring for a client postop after receiving moderate conscious sedation suddenly becomes restless and reports feeling lightheaded - CORRECT ANSWER=> Check the client's oxygen saturation level" "Assessing client who is 11 wks gestation and reports drinking ginger tea. signs of it's effectiveness - CORRECT ANSWER=> The client reports a decrease in episodes of nausea" "Teaching a client who newly diagnosed with DM. Instructions on manifestations of hypoglycemia - CORRECT ANSWER=> Irritability" "caring for a client with DVT - CORRECT ANSWER=> Instruct the client to elevate the affected extremity when sitting" "Providing info to a client immediately before Romberg test - CORRECT ANSWER=> I will be checking you once with your eyes open and once with them closed" "Providing teaching to parents of child with autism spectrum disorder - CORRECT ANSWER=> Use a reward system to modify the child's behavior" "Teaching a client undergoing ECT about adverse effects - CORRECT ANSWER=> Short term memory loss"
"Caring for a client who is in resuscitation phase of burn injury - CORRECT ANSWER=> Hyponatremia" "Teaching self administration of insulin to a client with short acting and intermediate acting insulin - CORRECT ANSWER=> Pinches the skin prior to injecting the insulin" "Teaching a client 26 wks gestation about a glucose tolerance test. - CORRECT ANSWER=> avoid caffeine" "Caring for a client who has hyperthyroidism - CORRECT ANSWER=> Tremors" "Caring for a newborn with herpes simplex virus which precautions should be initiated - CORRECT ANSWER=> Contact" "Postpartum nurse is caring for 4 clients which one should be on seizure precautions. - CORRECT ANSWER=> A client who is as 33 wks of gestation and has severe gestational hypertension" "Assessing an adolescnet who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Assess for adverse effects - CORRECT ANSWER=> Have you had any stomach pain or bloody stools" "Caring for older adult who is experiencing chronic anorexia and receiving tube feedings. Lab values that indicate additional nutrients are needed - CORRECT ANSWER=> Albumin 2.8 g/dL" "Teaching to school age child with asthma using albuterol dose inhaler instructions - CORRECT ANSWER=> Take the medication 15 min before playing sports" "Assessing a client with decreased visual acuity due to cataracts. Identify physiological changes - CORRECT ANSWER=> Increased opacity of the lens" "Mental health clinic caring for clients. Which of the following clients is using dissociation as a defense mechanism? - CORRECT ANSWER=> A client who was abused as a child describes the abuse as if it happened to someone else" "Assessing a 2 wk old newborn with a birth weight of 3.64 kg being breastfed. Indicators of effective breastfeeding - CORRECT ANSWER=> The newborn has 6 to 8 wet diapers per day"
"Preparing to administer a blood transfusion to a client. Ensure proper client identification - CORRECT ANSWER=> Verify the client and blood product information with another licensed nurse" "Reviewing client's right with the nurses on the unit. Informed consent promotes which of the following ethical principles - CORRECT ANSWER=> Autonomy" "Teaching about lithium to client who has bipolar disorder - CORRECT ANSWER=> Notify your provider if your experience increarsed thirst" "Change of shift report informs of newly admitted client with disoriented and combative during the night. Actions the day shift nurse should take - CORRECT ANSWER=> Move the client to a room near the nurses' station." "Caring for an 18-month old toddler who has a blood lead level of 3mcb/dL. Which of the following actions should the nurse take - CORRECT ANSWER=> Recommend re-screening in 1 year" "Assessing a client who has bipolar. Which of the following alterations in speech is the client using - CORRECT ANSWER=> Flight of Ideas" "Working in ED triaging 4 clients. Which of the following clients should the nurse recommend for treatment first? - CORRECT ANSWER=> A middle aged adult client who has unstable vital signs" "Admission assessment on a client who had a recent positive pregnancy test. First day of her last menstrual period was May 8. Nagel's rule EDB - CORRECT ANSWER=> February 15" "Assessing a client who received 2 units of packed RBCs 48 hr ago. Findings that indicate the therapy is effective? - CORRECT ANSWER=> Hemoglobin 14.9 g/dL" "Caring for a client who recently signed informed consent to donate a kidney to her sibling in ERF. States "I don't want my brother to die, but what if I need this kidney one day?" - CORRECT ANSWER=> You afraid that you other kidney will fail at some point after the organ donation" "A nurse is preparing to administer an IM injection to a client who is obese - CORRECT ANSWER=> Use the ventrogluteal site because it has a thick area of muscle and contains no large nerves or blood vessels."
identified as a characteristic of which personality disorder - CORRECT ANSWER=> Borderline- emotionally unstable, have troubled interpersonal relationships and often engage in harmful behaviors such as cutting, substance use and suicidal thoughts." "Nurse preceptor is evaluating the performance of newly licensed nurse. which action should the preceptor intervene on - CORRECT ANSWER=> Starts a task by determining what supplies are needed. Should gather prior to beginning task for effective time management." "Providing teaching about advance directives to a middle adult client. Which response indicates understanding? - CORRECT ANSWER=> I can designate my partner as my health care surrogate" "Teaching a group of newly licensed nurses about the need to complete an incident report. Which of the following is an example of reportable incident and an indication for completing a report - CORRECT ANSWER=> A nurse administered a medication via the wrong route." "Caring for a newborn immediately after delivery. Which interventions should be implemented to prevent heat loss by conduction? - CORRECT ANSWER=> Use a protective cover on the scale when weighting the infant." "Caring for a client in stage 4 of labor who is receiving oxytocin via continuous IV. Priority assessment - CORRECT ANSWER=> Amount of vaginal bleeding" "Preparing to transfer a client from ICU to the medical floor. Client was recently weaned from mechanical ventilation follow a pneumonectomy. Information to include in change of shift report - CORRECT ANSWER=> The time of the client's last dose of pain medication. So the receiving nurse can anticipate what time to give the next dose." "Charge nurse notices one of the nurses on the shift frequently violates unit policies by taking an extended amount of time on break. Statement that addresses the conflict - CORRECT ANSWER=> I would like to talk to you about the nit policies regarding break time." "Providing discharge teaching about disease management for a client who has a new diagnosis of DM. Priority activities - CORRECT ANSWER=> Ensure the client understand the medication regimen. Because this position limits the flow of th instilled solution out of the stomach and prevents aspiration."
"Caring for a client who has gastrointestinal bleeding and an NG tube in place. Action that should be taken while performing gastric lavage. - CORRECT ANSWER=> Ask the client to lie on the left side" "Planning to delegate client care tasks to an assistive personnel. Which task can be delegated? - CORRECT ANSWER=> Perform gastrectomy feeding through a client's established gastrostomy tube." "Providing teaching to client with peripheral arterial disease. Indications of understanding - CORRECT ANSWER=> Applies lubricating lotion to her feet to prevent cracked skin. Store the medication in the refrigerator." "Providing discharge teaching for preschool age child with a new prescription for Amoxicillian/clavulanate suspension. - CORRECT ANSWER=> Shake the medication bottle well before each dose is given. Report diarrhea to the provider immediately. Store medication in refrigerator" "Caring for a client with COPD and becomes extremely short of breath. Interventions by the nurse requires completion of an incident report - CORRECT ANSWER=> Increasing oxygen via nasal cannula to 6 L/min" "Assessing correct placement of a client's NG feeding tube prior to administering a bolus feeding. - CORRECT ANSWER=> Aspirate contents form the tube and verify the pH level" "Preparing to transfer a client to a rehab facility who had a stroke Family is concerned about the level of care the client will receive? - CORRECT ANSWER=> Facilitate an interdisciplinary conference at the new facility for the family" "Caring for a client receiving a continuous heparin infusion. Lab test to review prior to adjusting the client's heparin? - CORRECT ANSWER=> aPTT" "Providing care for a client with a colostomy - CORRECT ANSWER=> Place the skin barrier over the stoma and hold it for 30 seconds." "Preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5 mL to administer IM to an agitated client - CORRECT ANSWER=> Inject air into both vials prior to withdrawing the medications."
"Assessing a client who has depressive disorder taking amitriptyline. Identify adverse effects. - CORRECT ANSWER=> Blurred vision" "School nurse is notified of an emergency which several children were injured following the collapse of playground equipment. - CORRECT ANSWER=> Survey the scene for potential hazards to staff and children." "Manger preparing an educational session for staff about how to provide cost effective care - CORRECT ANSWER=> Delegate non-nursing tasks to ancillary staff." "Creating plan of care for child with acute lymphooid leukemia and an absolute netrophil count of 400/mm3 - CORRECT ANSWER=> Administer granulocyte colony-stimulating factor to the child" "Providing teaching to a client who speaks a different language than the nurse about an upcoming diagnostic procedure. - CORRECT ANSWER=> Use pictures to illustrate the procedure to the client" "Caring for a client with a prescription for continuous passive motion machine following total knee arthroplasty - CORRECT ANSWER=> Turn off the CPM machine during mealtime." "Caring for a client who is receiving positive end expiratory pressure via mechanical ventilation. Adverse effects of PEEP - CORRECT ANSWER=> Tension pneumothorax" "Performing an abdominal assessment on a client Sequence of actions - CORRECT ANSWER=> Inspect, auscultate, purcuss then palpate." "Caring for a client with a new prescription of Clonidine. Adverse side effects - CORRECT ANSWER=> Dry mouth" "Reviewing lab results of a toddler with hemophilia A. Which aPTT values should the nurse expect? - CORRECT ANSWER=> 45 seconds" "Updating the plan of care for a client who is 48 hr post op following laryngectomy and unable to speak. Plan to take first - CORRECT ANSWER=> Determine the client's reading skills" "Caring for a client who asks about taking ginseng to improve her appetite. Identify that ginseng can decrease the effectiveness of which medication. - CORRECT ANSWER=> Timolol"
"Preparing client for paracentesis. Action to take - CORRECT ANSWER=> Instruct the client to void." "Rn observing a LPN and a AP move a client up in bed. When should the nurse intervene - CORRECT ANSWER=> The LPN and the AP grasp the client under his arms to life him up in bed." "Assessing a client who has had a stroke. For which shoudl the nurse initiate referral for occupational therapy - CORRECT ANSWER=> Difficulty performing ADLs" "Assessing a client taking propranolol. Indication of adverse reaction - CORRECT ANSWER=> Coughing at night." "Conducting visual acuity testing using the Snellen letter chart for a school age child with eyeglasses - CORRECT ANSWER=> You should keep both eyes open during the testing." "Caring for a multiparous client following a vaccum assisted birth. Assess for which possible complication. - CORRECT ANSWER=> Cervical laceration" “Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? - CORRECT ANSWER=> Ask another nurse to witness the disposal of the new patch." "Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98 seconds and INR 1.8 - CORRECT ANSWER=> Withhold the heparin infusion" "A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which indicates the client has a detached retina - CORRECT ANSWER=> Floating dark spots" "infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement. finding to report to provider - CORRECT ANSWER=> Irritability when being held. signifies increased ICP" "Assessing a newborn heart rate follow actions the nurse should take - CORRECT ANSWER=> Auscultate the apical pulse and count beats for at least 1 min." "Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool - CORRECT ANSWER=> Insert a lubricated gloved finger and advance along the rectal wall."
"Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate family to obtain consent - CORRECT ANSWER=> Proceed with provision of medical care" "Client who has fluid volume overload. Which tasks can nurse delegate to UAP - CORRECT ANSWER=> Measure the client's daily weight" "Checking for Chvostek's sign - CORRECT ANSWER=> The nurse should assess for a Chvostek's sign by tapping the client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that indicates hypocalcemia." "Reviewing urinalysis report of client with acute glomerulonephritis expected findings - CORRECT ANSWER=> Protein" "Newly admitted child. Which of the following actions should the nurse include in the plan - CORRECT ANSWER=> Administer high dose antibiotic therapy" "Client with cancer deciding between two treatment plans - CORRECT ANSWER=> tell me more about your understanding of the options." "Caring for a client receiving hemodalysis with AV fistula - CORRECT ANSWER=> Auscultate the affected extremity for a bruit" "Oncology unit nurse is administering doxorubicin to breast cancer patient - CORRECT ANSWER=> Inspect the client's mucosa for petechiae every 8 hrs. This med causes thrombocytopenia and increases the risk of bleeding" "Hospice nurse consulting about receiving home services - CORRECT ANSWER=> We can expect the hospice nurse to provide support for us after our mother's death" "Client with major depressive disorder has signed informed consetn for ECT. Client states I'm not sure about this now I'm afraid it's too risky - CORRECT ANSWER=> You have the right to refuse to have the ECT even after you have agreed to it" "Discharge instructions about newborn care to a client 2 days postpartum - CORRECT ANSWER=> I will cover my baby's body when I wash her hair. I will use the bulb syringe first in her mouth and then in her nose."
"Assigning task roles for group of clients in community mental health clinic. Which should be assigned to group functioning the orienter - CORRECT ANSWER=> Noting the progress of the group toward assigned goals" "Nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster - CORRECT ANSWER=> A client who has cellulitis and is receiving oral antibiotics every 8 hours." "Developing a client education program about osteoporosis for older adult clients - CORRECT ANSWER=> Sedentary lifestyle" "Charge is providing educational session about infection control for a group of staff on isolation precautions - CORRECT ANSWER=> A client who requires airborne precautions should be placed in a negative pressure airflow room" "Preparing to assist with a thoracentesis for a client who has pleurisy - CORRECT ANSWER=> Instruct the client to avoid deep breathing during the procedure" “Professional Responsibilities: Educating Staff About Client Advocacy - CORRECT ANSWER=> Advocacy is one of the most important roles of the nurse. Nurses must act as advocates even when they disagree with the client's decision. Nurses are clients' voice when the healthcare system is not acting in their best interest." "Managing Client Care: Responding to an Incomplete Delegated Task - CORRECT ANSWER=> First assess why the task was not completed. Complete the task on your own if appropriate. Then resolve the issue with the tech/write report if necessary." "Managing Client Care: Utilizing the Five Rights of Delegation - CORRECT ANSWER=> Right task Right circumstance Right person Right direction and communication Right supervision and evaluation" "Gastrointestinal Therapeutic Procedures: Priority Findings Following a Colostomy - CORRECT ANSWER=> Monitor site for infection. Empty bag when full."
"Guidelines for Healthy Eating: Understanding Nutritional Food Labels - CORRECT ANSWER=> Ingredients are listed from the most to the least quantity." "Health Promotion of Infants (2 Days to 1 Year): Finding to Report - CORRECT ANSWER=> The moro, walking/stepping, and rooting reflex should disappear by 4 months. Tonic neck reflex should go away by 5-7 months." "Musculoskeletal Congenital Disorders: Screening for Idiopathic Scoliosis - CORRECT ANSWER=> Have pt bend over and feel spine. It should be straight and symmetrical." "Psychosocial Issues of Infants, Children, and Adolescents: Caring for a Child Following Abuse - CORRECT ANSWER=> Do not allow the abuser to see the child." "Neurocognitive Disorders: Documenting Dementia Findings - CORRECT ANSWER=> Vital signs may be unstable and abnormal due to medical illness." "Neurocognitive Disorders: Managing a Client Who Has Dementia - CORRECT ANSWER=> Occurrence of impairments in memory, judgement, ability to focus, and ability to calculate; these impairments may fluctuate throughout the day. Level of consciousness is usually altered. Restlessness, agitation are common; sundowning (confusion during the night) may occur; behaviors may increase or decrease daily. Personality change is rapid. Some perceptual disturbances may be present, such as hallucinations and illusions." "Sensory Perception: Communicating With a Client Who Has Hearing Loss - CORRECT ANSWER=> Speak loudly and clearly. Use white board if necessary." "Gastrointestinal Therapeutic Procedures: Evaluating a Client s Understanding of Diet - CORRECT ANSWER=> Ask client to describe correct diet and demonstrate food choices." "Parkinson's Disease: Client Safety - CORRECT ANSWER=> Removes items from the home that the client could trip on." "Connective Tissue Disorders: Long-Term Therapy - CORRECT ANSWER=> Calcium channel blockers, amlodipine"
"Medications Affecting Coagulation: Enoxaparin - CORRECT ANSWER=> Prevents DVT. Can also be used during pregnancy." "Medications Affecting Urinary Output: Recognizing Complication Caused by a Medication Interaction - CORRECT ANSWER=> Watch for excessive urination and/or no urination. This is evidence of a kidney problem." "Medications for Psychotic Disorders: Adverse Effects of Conventional Antipsychotics - CORRECT ANSWER=> Stiffness, shakiness, jaw movements, sleepiness, weight gain, sexual problems" "Miscellaneous Pain Medications: Migraine Medications - CORRECT ANSWER=> Take preventatively to avoid migraines." "Medications for Children and Adolescents Who Have Mental Health Issues: Client Teaching for Methylphenidate - CORRECT ANSWER=> This med can be habit-forming. Do not stop taking unless Dr tells you to." "Tuberculosis: Identifying a Positive Result of a Mantoux Skin Test - CORRECT ANSWER=> There will be an inflamed bump the size of a pencil eraser." "Medications for Bipolar Disorders: Laboratory Value to Report to Provider - CORRECT ANSWER=> Lithium level therapeutic: 0.4-0.8" "Diabetes Mellitus Management: Client Teaching About Foot Care - CORRECT ANSWER=> Check feet often for ulcers. Don't cut toenails too short. Avoid moisture on feet." "Intravenous Therapy: Peripheral Catheter Insertion - CORRECT ANSWER=> Apply tourniquet. Find a bouncer vein. Advance needle until you get blood return. Remove needle and advance catheter." "Mobility and Immobility: Preventing Foot Drop - CORRECT ANSWER=> Lift foot higher than usual when walking" "Airway Management: Tracheostomy Care - CORRECT ANSWER=> Always keep an extra trach tube in the correct size, and one in a smaller size at the bedside." "Cancer Treatment Options: Adverse Effects of Radiation Therapy - CORRECT ANSWER=> Sunburn-like skin, fatigue"
"Hearing aid care - CORRECT ANSWER=> Remove aids to disconnect battery safely." "Sickle cell anemia management - CORRECT ANSWER=> Teach parents about home disease management." "Hyperosmolar dehydration - CORRECT ANSWER=> Add water to formula for enteral feeding." "Patient identification - CORRECT ANSWER=> Use telephone number as client identifier." "Transfusion monitoring - CORRECT ANSWER=> Vital signs monitored hourly during transfusion." "Veracity in nursing - CORRECT ANSWER=> Truthfulness about treatment effects and risks." "GERD dietary advice - CORRECT ANSWER=> Avoid foods containing chocolate for relief." "Mental health assessment - CORRECT ANSWER=> Prioritize questions about self-harm thoughts." "Ostomy care - CORRECT ANSWER=> Empty pouch when half full for hygiene." "Peripheral IV catheter - CORRECT ANSWER=> Select site proximal to previous venipuncture." "Progressive relaxation technique - CORRECT ANSWER=> Tighten and release muscle groups to reduce stress." "Patient Self-Determination Act - CORRECT ANSWER=> Document advance directives during admission." "Child play therapy - CORRECT ANSWER=> Encourage preschoolers to engage with toys." "Antiembolic stockings - CORRECT ANSWER=> Measure legs for proper stocking size fitting." "Sterile dressing change - CORRECT ANSWER=> Mask and create sterile field before dressing." "Sterile field - CORRECT ANSWER=> A designated area free from pathogens." "Electroconvulsive therapy - CORRECT ANSWER=> Treatment for severe depression using electrical stimulation."
"Placental abruption - CORRECT ANSWER=> Premature separation of the placenta from the uterus." "Cataracts - CORRECT ANSWER=> Clouding of the lens causing vision impairment." "Transcutaneous electrical nerve stimulation (TENS) - CORRECT ANSWER=> Pain relief method using electrical impulses." "Bacterial meningitis - CORRECT ANSWER=> Infection of the protective membranes covering the brain." "Droplet precautions - CORRECT ANSWER=> Infection control measures for respiratory pathogens." "IV fluid intake calculation - CORRECT ANSWER=> Total volume of fluids administered intravenously." "Benzodiazepine toxicity - CORRECT ANSWER=> Overdose symptoms from benzodiazepine medications." "Spironolactone - CORRECT ANSWER=> Diuretic medication that retains potassium." "Misoprostol - CORRECT ANSWER=> Medication used for labor induction." "Skeletal traction - CORRECT ANSWER=> Method to stabilize fractures using weights." "Disulfiram - CORRECT ANSWER=> Medication that causes adverse effects with alcohol." "Preeclampsia - CORRECT ANSWER=> Pregnancy complication characterized by high blood pressure." "Digoxin toxicity - CORRECT ANSWER=> Toxic effects from digoxin overdose, like blurred vision." "Client rights - CORRECT ANSWER=> Patients' entitlements regarding their treatment choices." "Tonsillectomy - CORRECT ANSWER=> Surgical removal of the tonsils." "Positive airflow - CORRECT ANSWER=> Airflow direction to prevent contamination."
