RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT 2019
B EXAM 2024-2025 QUESTIONS AND ANSWERS 100 % PASS
SOLUTION A+ GRADE
A nurse is teaching a bout adverse effects with a client who is s tarting to take captopril.
Which of the following findings should the nurse identify a s an adverse effect of the
medication to report to the provider?
Cough
This is due to the buildup of bradykinin in the lungs. The client should report this to the
provider.
A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm
Hg. and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the
following acid-base imbalances?
Respiratory acidosis
A client who has respiratory acidosis will have decreased pH below the expected reference
range of 7.35-7.45, an increased PaCO2 above the expected reference range of 35-45 mm
Hg, and an HCO3 within the expected reference range of 22-26 mEq/L.
A nurse in a provider’s office is assessing an adolescent who has been taking ibuprofen for 6
months to treat juvenile i diopathic arthritis. Which of the following questions should the
nurse ask to assess for an a dverse effect of this med?
“Have you had any stomach pain or bloody stools?”
These are an indication of gastrointestinal bleeding, an adverse effect of ibuprofen.
A nurse in a pediatric unit has received a change-of-shift report for four children. Which of
the following children should the nurse assess first?
A 10-year-old child who is awaiting surgery f or an appendectomy and experienced sudden
relief from pain.
Using the urgent vs nonurgent approach to client care, the nurse should determine that the
client to assess first is the child awaiting an appendectomy who suddenly experiences pain
relief as this can be an i ndication of peritonitis from a ruptured appendix. The nurse
should notify the provider immediately.
,A nurse on an inpatient u nit is caring for a client who has schizophrenia and recently started
taking risperidone. Which of the following actions should the nurse take?
Implement fall precautions for the client.
Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. The
nurse should initiate fall precautions for the client.
A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse
should identify which o f the following physiological changes is the cause of the client’s
visual loss?
Increased opacity of the lens
A cataract is a cloudy or opaque area in the lens o f the eye that inhibits light penetration.
A nurse is caring for a c lient following a vacuum-assisted birth. The nurse should monitor the
client for which of the following complications related to vacuum-assisted birth?
Cervical laceration
Complications are perineal, vaginal, or cervical lacerations.
A nurse is updating the plan of care for a client who is 48 hr. post-op following a
laryngectomy and is unable to speak. W hich of the following actions should the nurse
plan to take first?
Determine the client’s reading skills
Using the nursing process to assess the client, determine the client’s level of reading skills
and cognition. The nurse can best provide the client with a variety of customized
techniques to practice and use after verbal skills are lost.
A nurse is caring for a s chool-aged child who has dehydration and is receiving an oral
rehydration solution. Which of the following lab results indicates that the treatment
regimen is effective?
Serum sodium 138 mEq/L
,Sodium level of 138 mEq/L, is within the expected reference range of 136-145 mEq/L and is
an indication that the child is responding to the oral rehydration solution.
A school nurse is notified of an emergency in which several children were injured following
the collapse of playground e quipment. Upon arrival at the playground, which of the
following actions should the nurse take f irst?
Survey the scene for potential hazards to staff and children.
Using the nursing process, assess the situation. By s urveying the scene, the nurse can
identify potential hazards to staff and children. These findings allow the nurse and staff to
enter the scene and safely provide care to injured children and help decrease the risk of
further injury.
A nurse in an ED is caring for a client who is unconscious and requires emergency medical
procedures. The nurse is unable to locate members of the client’s family to obtain
consent. Which of the following a ctions should the nurse take?
Proceed with provision for medical care.
When a client is unable to give informed consent in an emergency, health care personnel
can proceed with necessary life-saving care because the law considers this implied
consent.
A nurse is caring for a s chool-aged child who is taking valproic acid. The nurse should expect
the provider to order w hich of the following diagnostic tests?
Serum liver enzyme levels.
Valproic acid can cause hepatic toxicity. The nurse should expect the provider to prescribe
lab tests to assess the child’s liver function prior to and periodically during therapy.
A nurse manager is preparing to teach a group of newly licensed nurses about effective time
management. Which o f the following steps of the time management process should the
nurse manager include as t he priority?
Making a list of activities to complete.
, According to evidence-based practice, p lanning is the most important step in managing time
effectively. The nurse manager should include making a list of activities to complete as the
priority. Other planning activities include setting goals, establishing priorities, and
scheduling activities.
A nurse is caring for a c lient who has a pulmonary embolism. The client is receiving heparin
via continuous IV infusion at 1200 units/hr and warfarin 5 mg PO daily. The morning lab
values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions
should the nurse take?
Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT
by a factor of 1.5-2, making the aPTT 60-80 seconds. An aPTT level of 98 is above the
expected reference range, indicating that the dosage should be reduced, or the infusion
withheld until the aPTT returns to the therapeutic range.
A nurse is providing t eaching to a school-age child who has asthma about using an albuterol
metered-dose inhaler. W hich of the following instructions should the nurse include?
Take the medication 15 mins before playing sports.
Take 5-20 min prior to exercise to promote bronchodilation. The meds effects begin
immediately, peak in 30-60 min, and can last for up to 5 hr.
A home health nurse is evaluating a school aged child who has cystic fibrosis. The nurse
should initiate a request for a h igh-frequency chest compression vest in response to
which of the following parent statements?
“My child has only a small amount of mucus after percussion therapy.”
The nurse should recommend a high-frequency chest compression vest for a child who has
inadequate results from other airway clearance therapy techniques. Older children often
require other techniques in addition to percussion and postural drainage to achieve
adequate mucus expectoration.
A nurse is planning care for a patient who is receiving chemotherapy and has neutropenia.
Which of the following i nterventions should the nurse include in the plan?
B EXAM 2024-2025 QUESTIONS AND ANSWERS 100 % PASS
SOLUTION A+ GRADE
A nurse is teaching a bout adverse effects with a client who is s tarting to take captopril.
Which of the following findings should the nurse identify a s an adverse effect of the
medication to report to the provider?
Cough
This is due to the buildup of bradykinin in the lungs. The client should report this to the
provider.
A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm
Hg. and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the
following acid-base imbalances?
Respiratory acidosis
A client who has respiratory acidosis will have decreased pH below the expected reference
range of 7.35-7.45, an increased PaCO2 above the expected reference range of 35-45 mm
Hg, and an HCO3 within the expected reference range of 22-26 mEq/L.
A nurse in a provider’s office is assessing an adolescent who has been taking ibuprofen for 6
months to treat juvenile i diopathic arthritis. Which of the following questions should the
nurse ask to assess for an a dverse effect of this med?
“Have you had any stomach pain or bloody stools?”
These are an indication of gastrointestinal bleeding, an adverse effect of ibuprofen.
A nurse in a pediatric unit has received a change-of-shift report for four children. Which of
the following children should the nurse assess first?
A 10-year-old child who is awaiting surgery f or an appendectomy and experienced sudden
relief from pain.
Using the urgent vs nonurgent approach to client care, the nurse should determine that the
client to assess first is the child awaiting an appendectomy who suddenly experiences pain
relief as this can be an i ndication of peritonitis from a ruptured appendix. The nurse
should notify the provider immediately.
,A nurse on an inpatient u nit is caring for a client who has schizophrenia and recently started
taking risperidone. Which of the following actions should the nurse take?
Implement fall precautions for the client.
Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. The
nurse should initiate fall precautions for the client.
A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse
should identify which o f the following physiological changes is the cause of the client’s
visual loss?
Increased opacity of the lens
A cataract is a cloudy or opaque area in the lens o f the eye that inhibits light penetration.
A nurse is caring for a c lient following a vacuum-assisted birth. The nurse should monitor the
client for which of the following complications related to vacuum-assisted birth?
Cervical laceration
Complications are perineal, vaginal, or cervical lacerations.
A nurse is updating the plan of care for a client who is 48 hr. post-op following a
laryngectomy and is unable to speak. W hich of the following actions should the nurse
plan to take first?
Determine the client’s reading skills
Using the nursing process to assess the client, determine the client’s level of reading skills
and cognition. The nurse can best provide the client with a variety of customized
techniques to practice and use after verbal skills are lost.
A nurse is caring for a s chool-aged child who has dehydration and is receiving an oral
rehydration solution. Which of the following lab results indicates that the treatment
regimen is effective?
Serum sodium 138 mEq/L
,Sodium level of 138 mEq/L, is within the expected reference range of 136-145 mEq/L and is
an indication that the child is responding to the oral rehydration solution.
A school nurse is notified of an emergency in which several children were injured following
the collapse of playground e quipment. Upon arrival at the playground, which of the
following actions should the nurse take f irst?
Survey the scene for potential hazards to staff and children.
Using the nursing process, assess the situation. By s urveying the scene, the nurse can
identify potential hazards to staff and children. These findings allow the nurse and staff to
enter the scene and safely provide care to injured children and help decrease the risk of
further injury.
A nurse in an ED is caring for a client who is unconscious and requires emergency medical
procedures. The nurse is unable to locate members of the client’s family to obtain
consent. Which of the following a ctions should the nurse take?
Proceed with provision for medical care.
When a client is unable to give informed consent in an emergency, health care personnel
can proceed with necessary life-saving care because the law considers this implied
consent.
A nurse is caring for a s chool-aged child who is taking valproic acid. The nurse should expect
the provider to order w hich of the following diagnostic tests?
Serum liver enzyme levels.
Valproic acid can cause hepatic toxicity. The nurse should expect the provider to prescribe
lab tests to assess the child’s liver function prior to and periodically during therapy.
A nurse manager is preparing to teach a group of newly licensed nurses about effective time
management. Which o f the following steps of the time management process should the
nurse manager include as t he priority?
Making a list of activities to complete.
, According to evidence-based practice, p lanning is the most important step in managing time
effectively. The nurse manager should include making a list of activities to complete as the
priority. Other planning activities include setting goals, establishing priorities, and
scheduling activities.
A nurse is caring for a c lient who has a pulmonary embolism. The client is receiving heparin
via continuous IV infusion at 1200 units/hr and warfarin 5 mg PO daily. The morning lab
values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions
should the nurse take?
Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT
by a factor of 1.5-2, making the aPTT 60-80 seconds. An aPTT level of 98 is above the
expected reference range, indicating that the dosage should be reduced, or the infusion
withheld until the aPTT returns to the therapeutic range.
A nurse is providing t eaching to a school-age child who has asthma about using an albuterol
metered-dose inhaler. W hich of the following instructions should the nurse include?
Take the medication 15 mins before playing sports.
Take 5-20 min prior to exercise to promote bronchodilation. The meds effects begin
immediately, peak in 30-60 min, and can last for up to 5 hr.
A home health nurse is evaluating a school aged child who has cystic fibrosis. The nurse
should initiate a request for a h igh-frequency chest compression vest in response to
which of the following parent statements?
“My child has only a small amount of mucus after percussion therapy.”
The nurse should recommend a high-frequency chest compression vest for a child who has
inadequate results from other airway clearance therapy techniques. Older children often
require other techniques in addition to percussion and postural drainage to achieve
adequate mucus expectoration.
A nurse is planning care for a patient who is receiving chemotherapy and has neutropenia.
Which of the following i nterventions should the nurse include in the plan?
