ATI CAPSTONE COMPREHENSIVE ASSESSMENT A COMPLETE ACTUAL EXAM / QUESTIONS AND CORRECT DETAILED ANSWERS
A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take?
a. Instruct the client to lie prone with arms by the sides
b. Complete a surgical checklist on the client
c. Remind the client that there is minimal discomfort during the removal process
d. Place an occlusive dressing over the site once the tube is removed ✔️d. Place an occlusive dressing over the site once the tube is removed
Observe the site for drainage.
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the clients
room? SATA
a. Oxygen equipment
b. Incentive spirometer
c. Pulse oximeter
d. Sterile dressing
e. Suture removal kit ✔️a, c, d
a. Oxygen equipment for SOB
b. Pulse ox to monitor ox sat during procedure
d. Sterile dressing to apply to the puncture site
Associated manifestation of Hypokalemia ✔️Hypoactive bowel sounds
The nurse is assessing the client for Chvostek's sign. Which of the following actions should the nurse take?
a. Apply a BP cuff to the client's arm
b. Place a stethoscope bell over the client's carotid artery
c. Ask the client to lower their chin to their chest
d. Tap lightly on the client's cheek ✔️d. Tap lightly on the client's cheek
Tap over the facial nerve just below and anterior to the ear to elicit Chvostek's sign.
A positive sign = Facial twitching on the side of the face
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which of the following findings are manifestations of
hypocalcemia? SATA
a. Tingling in fingers
b. Poor skin turgor
c. Abdominal pain
d. Elevated temperature
e. Muscle twitching ✔️a, c, e
, Numbness and tingling in fingers and toes, abdominal cramps and diarrhea, and muscle twitching are manifestations of hypocalcemia.
Associated manifestation of Hypocalcemia ✔️Positive Trousseau's sign
Respiratory Diagnostic Procedures: Planning Care for a Client Who Is Scheduled for a Thoracentesis ✔️Preprocedure:
- Percussion, auscultation, radiography, or sonography is used to locate the effusion and needle insertion site.
- Assist the older client to maintain still for the procedure
- Position the client sitting upright with arms and shoulders raised and supported on pillows and/or an overbed table and with feet and legs
well-supported.
- Remain stills, no coughing or talking
Intraprocedure:
- Aseptic technique
- Monitor VS, skin color, and ox sat
- Amount of fluid removed is limited to 1L at a time to prevent re-expansion pulmonary edema
Postprocedure:
- Apply dressing over puncture site
- Assess for bleeding or drainage
- Monitor VS and respiratory status hourly for the first several hours
- Encourage deep breathe to assist with lung expansion
- Obtain a postprocedure cxr
Thoracentesis ✔️Thoracentesis is the surgical perforation of the chest wall and pleural space with a large-bore needle. It is performed to obtain
specimens for diagnostic evaluation, instill medication into the pleural space, and remove fluid or air from the pleural space for therapeutic
relief of pleural pressure.
Associated manifestation of Hyponatremia ✔️Bounding pulse
Electrolyte Imbalances: Identifying Manifestations of a Calcium Imbalance ✔️Hypocalcemia:
- Level: <9 mg/dL
- Risk factors: Calcium deficit, diarrhea, end-stage kidney disease, wound drainage; alkalosis, acute pancreatitis, immobility, parathyroid
removal/damage
- S&S: Tetany (most common manifestation), paresthesia of the fingers and lips, muscle twitches,
seizure, muscle spasms, hyperactive DTRs, positive Chvostek's sign (facial twitching), positive Trousseau's sign (hand/finger spasms with BP cuff
inflation), cardiovascular irregularities, diarrhea, abdominal cramps
- Tx: Vitamin D supplements
- Complications: Cardiac arrest
A nurse is reviewing information with a client who is scheduled for pulmonary function tests. Which of the following statements should the
nurse make?
a. "Do not use inhaler medications for 6 hr following the test."
A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take?
a. Instruct the client to lie prone with arms by the sides
b. Complete a surgical checklist on the client
c. Remind the client that there is minimal discomfort during the removal process
d. Place an occlusive dressing over the site once the tube is removed ✔️d. Place an occlusive dressing over the site once the tube is removed
Observe the site for drainage.
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the clients
room? SATA
a. Oxygen equipment
b. Incentive spirometer
c. Pulse oximeter
d. Sterile dressing
e. Suture removal kit ✔️a, c, d
a. Oxygen equipment for SOB
b. Pulse ox to monitor ox sat during procedure
d. Sterile dressing to apply to the puncture site
Associated manifestation of Hypokalemia ✔️Hypoactive bowel sounds
The nurse is assessing the client for Chvostek's sign. Which of the following actions should the nurse take?
a. Apply a BP cuff to the client's arm
b. Place a stethoscope bell over the client's carotid artery
c. Ask the client to lower their chin to their chest
d. Tap lightly on the client's cheek ✔️d. Tap lightly on the client's cheek
Tap over the facial nerve just below and anterior to the ear to elicit Chvostek's sign.
A positive sign = Facial twitching on the side of the face
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which of the following findings are manifestations of
hypocalcemia? SATA
a. Tingling in fingers
b. Poor skin turgor
c. Abdominal pain
d. Elevated temperature
e. Muscle twitching ✔️a, c, e
, Numbness and tingling in fingers and toes, abdominal cramps and diarrhea, and muscle twitching are manifestations of hypocalcemia.
Associated manifestation of Hypocalcemia ✔️Positive Trousseau's sign
Respiratory Diagnostic Procedures: Planning Care for a Client Who Is Scheduled for a Thoracentesis ✔️Preprocedure:
- Percussion, auscultation, radiography, or sonography is used to locate the effusion and needle insertion site.
- Assist the older client to maintain still for the procedure
- Position the client sitting upright with arms and shoulders raised and supported on pillows and/or an overbed table and with feet and legs
well-supported.
- Remain stills, no coughing or talking
Intraprocedure:
- Aseptic technique
- Monitor VS, skin color, and ox sat
- Amount of fluid removed is limited to 1L at a time to prevent re-expansion pulmonary edema
Postprocedure:
- Apply dressing over puncture site
- Assess for bleeding or drainage
- Monitor VS and respiratory status hourly for the first several hours
- Encourage deep breathe to assist with lung expansion
- Obtain a postprocedure cxr
Thoracentesis ✔️Thoracentesis is the surgical perforation of the chest wall and pleural space with a large-bore needle. It is performed to obtain
specimens for diagnostic evaluation, instill medication into the pleural space, and remove fluid or air from the pleural space for therapeutic
relief of pleural pressure.
Associated manifestation of Hyponatremia ✔️Bounding pulse
Electrolyte Imbalances: Identifying Manifestations of a Calcium Imbalance ✔️Hypocalcemia:
- Level: <9 mg/dL
- Risk factors: Calcium deficit, diarrhea, end-stage kidney disease, wound drainage; alkalosis, acute pancreatitis, immobility, parathyroid
removal/damage
- S&S: Tetany (most common manifestation), paresthesia of the fingers and lips, muscle twitches,
seizure, muscle spasms, hyperactive DTRs, positive Chvostek's sign (facial twitching), positive Trousseau's sign (hand/finger spasms with BP cuff
inflation), cardiovascular irregularities, diarrhea, abdominal cramps
- Tx: Vitamin D supplements
- Complications: Cardiac arrest
A nurse is reviewing information with a client who is scheduled for pulmonary function tests. Which of the following statements should the
nurse make?
a. "Do not use inhaler medications for 6 hr following the test."
