NSG 4060 Comprehensive ATI Practice

 RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT 2019 B /

 ATI COMPREHENSIVE PRACTICE B

A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago.

Which 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 a re administered to clients who

have a decreased level of hemoglobin or hematocrit. This h emoglobin level

is within the expected reference range of 14 to 18 g/dL for males and 12 to

16 g/dL for females, indicating the therapy has been effective.

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 vs unstable approach t o client care, the nurse should

recommend priority treatment for the client who has u nstable vital signs

because this client requires immediate treatment to reduce the risk of further

injury o r possible death.

A nurse is caring for a c lient who has fluid volume overload. Which of the following

tasks should the nurse delegate t o 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.

A nurse is preparing t o 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 t he

amount in grams the nurse should administer?

18 g

A nurse is conduction a physical examination for an adolescent and is assessing

the range of motion of the legs. W hich 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.

A nurse is caring for a c lient who has hyperthyroidism. Which of the following

findings should the nurse expect?

Tremors

Tremors are a manifestation of hyperthyroidism, along with tachycardia,

diaphoresis, weight loss, insomnia, and exophthalmia.

A nurse is assessing a school-aged child who has bacterial meningitis. Which of the

following findings should the n urse expect?

Nuchal rigidity

This is a manifestation of bacterial meningitis.

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.

A nurse is preparing t o 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.

A nurse in the ED is a ssessing a preschooler who has a facial laceration. The nurse

should identify which of the f ollowing 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.

A nurse is preparing t o teach about dietary management to a client who has

Crohn’s disease and an enteroenteric f istula. Which of the following nutrients

should the nurse instruct the client to decrease in their d iet?

Fiber

The nurse should instruct the client to consume a low-fiber diet to reduce

diarrhea and inflammation.

A nurse is caring for a c lient 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.

A nurse is preparing t o 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 t issue.

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 t hey will promote

bone health by increasing calcium and phosphorus levels.

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 t he following interventions should the nurse

identify as the priority?

Initiate transmission-based precautions

When using the urgent vs 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.

A nurse is caring for a c lient 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, t he nurse should attempt to flush or aspirate the client’s tube

to remove the clog.

A home health care nurse is developing a teaching plan for a client who has a new

ileostomy. Which of the following i nstructions should the nurse include?

Empty the appliance when it is one-third t o one-half full.

The ileostomy pouch should be emptied when it is o ne-third to one-half full

to prevent stool leakage and skin irritation.

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.

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.

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.

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 intake of foods that contain tyramine due to adverse

effects, such as hypertension.

A nurse is planning care for a client who has rheumatoid arthritis and has moderate

to severe pain in multiple joints. W hich 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.

A nurse is caring for a c lient who is receiving continuous bladder irrigation

following a transurethral resection of the prostate. The client reports bladder

spasms, and the nurse observes a decreased u rinary output. Which of the following

action should the nurse take?

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 n ot

clear.

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 w ill 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.

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?

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