ATI Capstone Proctored
Comprehensive Assessment Form A
Exam Questions And Answers
/. Electrolyte Imbalances: Identifying Manifestations of a Calcium Imbalance - Answer-
✅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
/.Associated manifestation of Hypocalcemia - Answer-✅Positive Trousseau's sign
/.Associated manifestation of Hyperkalemia - Answer-✅ECG with tall, peaked t-waves
/.Associated manifestation of Hyponatremia - Answer-✅Bounding pulse
/.Associated manifestation of Hypokalemia - Answer-✅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 - Answer-✅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 - Answer-✅a, c, e
Numbness and tingling in fingers and toes, abdominal cramps and diarrhea, and muscle
twitching are manifestations of hypocalcemia.
/.Respiratory Diagnostic Procedures: Planning Care for a Client Who Is Scheduled for a
Thoracentesis - Answer-✅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 - Answer-✅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.
/.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."
b. "Do not smoke tobacco for 6-8 hr prior to the test."
c. "You will be asked to bear down and hold your breath during the test."
d. "The arterial blood flow to your hand will be evaluated as part of the test." - Answer-
✅b. "Do not smoke tobacco for 6-8 hr prior to the test."
To ensure accurate results
/.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
Comprehensive Assessment Form A
Exam Questions And Answers
/. Electrolyte Imbalances: Identifying Manifestations of a Calcium Imbalance - Answer-
✅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
/.Associated manifestation of Hypocalcemia - Answer-✅Positive Trousseau's sign
/.Associated manifestation of Hyperkalemia - Answer-✅ECG with tall, peaked t-waves
/.Associated manifestation of Hyponatremia - Answer-✅Bounding pulse
/.Associated manifestation of Hypokalemia - Answer-✅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 - Answer-✅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 - Answer-✅a, c, e
Numbness and tingling in fingers and toes, abdominal cramps and diarrhea, and muscle
twitching are manifestations of hypocalcemia.
/.Respiratory Diagnostic Procedures: Planning Care for a Client Who Is Scheduled for a
Thoracentesis - Answer-✅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 - Answer-✅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.
/.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."
b. "Do not smoke tobacco for 6-8 hr prior to the test."
c. "You will be asked to bear down and hold your breath during the test."
d. "The arterial blood flow to your hand will be evaluated as part of the test." - Answer-
✅b. "Do not smoke tobacco for 6-8 hr prior to the test."
To ensure accurate results
/.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
