RN ATI CAPSTONE PROCTORED COMPREHENSIVE
ASSESSMENT TEST B | ACTUAL TEST QUESTIONS AND
ANSWERS
• A nurse is caring for a patient who had abdominal surgery 24 hours
ago.Which of the followingactions is the priority?
• Assess fluid intake every 24 hours
• Ambulate three times a day
• Assist with deep breathing and coughing
• Monitor the incision site for findings of infection: C
The priority action the nurse should take when using the airway, breathing, circula- tion
approach to patient careis to assist the patient with deep breathing and coughing, which
reduces the risk for postoperative pneumonia.
• A nurse is talking with a patient who has stage IV breast cancer. The nurse
should recognize which of the following statements by the patient asa constructive
use of a defense mechanism?
• I have experienced physical discomfort when intimate with my partnersince
my diagnosis
• I wish other women would stop socializing with my partner
• I told my doctor that I would like to start a support group for other
womenwho are sick in mycommunity
• I used to mistrust my doctor, but now I know that she is the best one tocare
for me during myillness: C
This statement indicates that the patient is using the constructive defense mecha-nism sublimation
by devisinga socially acceptable alternative to facing a reality that she does not wish to accept.
• A nurse is caring for a patient who has immunosuppression and a
continu-ous IV infusion. Which ofthe following actions should the nurse take?
• Assess the patients IV site every 8 hours
• Check the patients WBC count every 48 hours
• Monitor the patients mouth every 8 hours
• Change the patients IV tubing every 48 hours: C
,• A nurse is caring for a 2-month-old infant who has Hirschsprung
disease(HD). Which of thefollowing areas should the nurse assess for manifesta-
tions of HD?
• Eyes area
• Chest area
• Lower abdominal area
• Bilateral lower extremities: C. Lower abdomen for distention and visible peri-
stalsis
Hirschsprung disease is a condition that affects the large intestine (colon) and causes problems
with passingstool. This is present at birth (congenital) as a resultof missing nerve cells in the
muscle of the baby's colon
• A nurse at a mental health clinic is caring for four patients. The nurse
should recognize that which of the following patients is using dissociation asa
defense mechanism?
• A patient forgets to buy their partner a birthday gift after a disagreement
• A patient who was abused as a child describes the abuse as if it happenedto
someone else.
• A patient who is shorter than average is verbally assertive with coworkers
• A patient states that they did not get a job promotion because the boss
didnot like them: B
• A nurse is providing teaching to a patient who has a new diagnosis of type
1 diabetes mellitus. The nurse should instruct the patient to monitor for which of
the following findings as a manifestation of hypoglycemia?
• irritability
• increased urination
• vomiting
• facial flushing: A
• A nurse in an outpatient mental health clinic is caring for four patients. The
nurse should recognize that which of the following patients is effectively using
sublimation as a defense mechanism?
• A patient who transfers their anger about their job onto their family and
thenapologizes
,• A patient who misses provider appointments because they say they are
toobusy
• A patient who channels their energy into a new hobby following the loss
oftheir job
• A patient whose partner died 4 years ago sets a place for him at dinner
eachnight: C
The nurse should identify that this patient is using the defense mechanism of sublimation by
channelingnegative feelings over the loss of their job into a newhobby.
• A hospice nurse is consulting with a patient and her family about
receivinghome services. Which of the following statements should the nurse
identifyas an indication that the family understands home hospice care?
• "We can expect the hospice nurse to provide support for us after
ourmother's death."
• A hospice nurse will come to the house each time our mother needs
painmedication
• Now that my mother is receiving hospice services, we will not be able toget
respite care
• Hospice care focuses on arranging treatment that will prolong our moth-er's
life: A
Hospice care includes bereavement services after a family member's death.
• A nurse is caring for a patient who has active pulmonary
tuberculosis.Whichof the following actions should the nurse take?
• Wear a surgical mask when providing patient care
• Have visitors maintain a distance of 1.8m (6 feet) from the patient
• Restrict fresh flowers from the patients room
• Assign the patient to a private room with negative air pressure: D
• A nurse is providing teaching to a patient who is at 24 weeks of gestation
and is scheduled for a 3- hr oral glucose tolerance test. Which of the following
instructions should the nurse include in the teaching?
, • Limit your fat intake for 72 hours before the test
• You will need to fast the night before the test
• We will collect a urine sample the day after testing
• A blood sample will be collected every 15 minutes during the test: B
• A nurse on a pediatric unit has received change-of-shift report for
fourchildren. Which of thefollowing children should the nurse assess first?
• A 6month old infant who has croup and an O2 saturation of 92% on roomair
• A 15 year old adolescent who is 2 hour postop following an open
reductionand internal fixation ofthe left ankle and is requesting pain medication
• A 3 year old toddler who has gastroenteritis, moderate dehydration, andhad
2 loose bowelmovements over the past 24 hours
• A 10-year-old child who is awaiting surgery for an appendectomy
andexperienced suddenrelief from pain.: D
• A nurse in a community center is providing an educational session to a
group of patients about ovarian cancer. Which of the following manifestations of
ovarian cancer should the nurse include in the teaching?
• Diarrhea
• Urinary retention
• Purulent discharge
• Abdominal bloating: D
• A nurse is caring for a patient who is postoperative after receiving moder-
ate (conscious) sedation. The patient suddenly becomes restless and reports
feeling lightheaded. Which of the following actions should the nurse take?
• Check the patients temperature
• Prepare to administer acetylcysteine to the patient
• Place the patient in the Trendelenburg position
• Check the patient's oxygen saturation level: D
Restlessness and lightheadedness are indications of hypoxia.
• A nurse working in an emergency department is triaging four patients.
Which of the followingpatients should the nurse recommend for treatmentfirst?
ASSESSMENT TEST B | ACTUAL TEST QUESTIONS AND
ANSWERS
• A nurse is caring for a patient who had abdominal surgery 24 hours
ago.Which of the followingactions is the priority?
• Assess fluid intake every 24 hours
• Ambulate three times a day
• Assist with deep breathing and coughing
• Monitor the incision site for findings of infection: C
The priority action the nurse should take when using the airway, breathing, circula- tion
approach to patient careis to assist the patient with deep breathing and coughing, which
reduces the risk for postoperative pneumonia.
• A nurse is talking with a patient who has stage IV breast cancer. The nurse
should recognize which of the following statements by the patient asa constructive
use of a defense mechanism?
• I have experienced physical discomfort when intimate with my partnersince
my diagnosis
• I wish other women would stop socializing with my partner
• I told my doctor that I would like to start a support group for other
womenwho are sick in mycommunity
• I used to mistrust my doctor, but now I know that she is the best one tocare
for me during myillness: C
This statement indicates that the patient is using the constructive defense mecha-nism sublimation
by devisinga socially acceptable alternative to facing a reality that she does not wish to accept.
• A nurse is caring for a patient who has immunosuppression and a
continu-ous IV infusion. Which ofthe following actions should the nurse take?
• Assess the patients IV site every 8 hours
• Check the patients WBC count every 48 hours
• Monitor the patients mouth every 8 hours
• Change the patients IV tubing every 48 hours: C
,• A nurse is caring for a 2-month-old infant who has Hirschsprung
disease(HD). Which of thefollowing areas should the nurse assess for manifesta-
tions of HD?
• Eyes area
• Chest area
• Lower abdominal area
• Bilateral lower extremities: C. Lower abdomen for distention and visible peri-
stalsis
Hirschsprung disease is a condition that affects the large intestine (colon) and causes problems
with passingstool. This is present at birth (congenital) as a resultof missing nerve cells in the
muscle of the baby's colon
• A nurse at a mental health clinic is caring for four patients. The nurse
should recognize that which of the following patients is using dissociation asa
defense mechanism?
• A patient forgets to buy their partner a birthday gift after a disagreement
• A patient who was abused as a child describes the abuse as if it happenedto
someone else.
• A patient who is shorter than average is verbally assertive with coworkers
• A patient states that they did not get a job promotion because the boss
didnot like them: B
• A nurse is providing teaching to a patient who has a new diagnosis of type
1 diabetes mellitus. The nurse should instruct the patient to monitor for which of
the following findings as a manifestation of hypoglycemia?
• irritability
• increased urination
• vomiting
• facial flushing: A
• A nurse in an outpatient mental health clinic is caring for four patients. The
nurse should recognize that which of the following patients is effectively using
sublimation as a defense mechanism?
• A patient who transfers their anger about their job onto their family and
thenapologizes
,• A patient who misses provider appointments because they say they are
toobusy
• A patient who channels their energy into a new hobby following the loss
oftheir job
• A patient whose partner died 4 years ago sets a place for him at dinner
eachnight: C
The nurse should identify that this patient is using the defense mechanism of sublimation by
channelingnegative feelings over the loss of their job into a newhobby.
• A hospice nurse is consulting with a patient and her family about
receivinghome services. Which of the following statements should the nurse
identifyas an indication that the family understands home hospice care?
• "We can expect the hospice nurse to provide support for us after
ourmother's death."
• A hospice nurse will come to the house each time our mother needs
painmedication
• Now that my mother is receiving hospice services, we will not be able toget
respite care
• Hospice care focuses on arranging treatment that will prolong our moth-er's
life: A
Hospice care includes bereavement services after a family member's death.
• A nurse is caring for a patient who has active pulmonary
tuberculosis.Whichof the following actions should the nurse take?
• Wear a surgical mask when providing patient care
• Have visitors maintain a distance of 1.8m (6 feet) from the patient
• Restrict fresh flowers from the patients room
• Assign the patient to a private room with negative air pressure: D
• A nurse is providing teaching to a patient who is at 24 weeks of gestation
and is scheduled for a 3- hr oral glucose tolerance test. Which of the following
instructions should the nurse include in the teaching?
, • Limit your fat intake for 72 hours before the test
• You will need to fast the night before the test
• We will collect a urine sample the day after testing
• A blood sample will be collected every 15 minutes during the test: B
• A nurse on a pediatric unit has received change-of-shift report for
fourchildren. Which of thefollowing children should the nurse assess first?
• A 6month old infant who has croup and an O2 saturation of 92% on roomair
• A 15 year old adolescent who is 2 hour postop following an open
reductionand internal fixation ofthe left ankle and is requesting pain medication
• A 3 year old toddler who has gastroenteritis, moderate dehydration, andhad
2 loose bowelmovements over the past 24 hours
• A 10-year-old child who is awaiting surgery for an appendectomy
andexperienced suddenrelief from pain.: D
• A nurse in a community center is providing an educational session to a
group of patients about ovarian cancer. Which of the following manifestations of
ovarian cancer should the nurse include in the teaching?
• Diarrhea
• Urinary retention
• Purulent discharge
• Abdominal bloating: D
• A nurse is caring for a patient who is postoperative after receiving moder-
ate (conscious) sedation. The patient suddenly becomes restless and reports
feeling lightheaded. Which of the following actions should the nurse take?
• Check the patients temperature
• Prepare to administer acetylcysteine to the patient
• Place the patient in the Trendelenburg position
• Check the patient's oxygen saturation level: D
Restlessness and lightheadedness are indications of hypoxia.
• A nurse working in an emergency department is triaging four patients.
Which of the followingpatients should the nurse recommend for treatmentfirst?
