RN ATI CAPSTONE PROCTORED COMPREHENSIVE
ASSESSMENT 2019 B
• .A nurse is assessing a client who received 2 units of packed RBCs 48 hours
ago. Which of the following findings should indicate to the nurse that the
therapyhas been effective?
Hemoglobin 14.9 g/dl
The nurse should identify that packed RBCs are administered to clients who have a
decreased level of hemoglobin or hematocrit. This hemoglobin 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
ofthe following clients should the nurse recommend for treatment first?
A middle adult client who has unstable vital signs.
Using the stable versus unstable approach to client care, the nurse should
recommend priority treatment for the client who has unstable vital signs because this
client requires immediate treatment to reduce the risk of further injury or possible
death.
• A nurse is caring for a client who has fluid volume overload. Which of
thefollowing tasks should the nurse delegate to 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 to 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
theamount in grams the nurse should administer?
18 g
• A nurse is conducting a physical examination for an adolescent and
isassessing the range of motion of the legs. Which 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 client 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.
Whichof the following findings should the nurse expect?
Nuchal rigidity
This is a manifestation of bacterial meningitis.
• A nurse is assessing a newborn’s heart rate. Which of the following
actionsshould the nurse take?
Auscultate the apical pulse at least 1 min.
The nurse should auscultate the apical pulse to obtain an accurate assessment of
heartrate 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 to 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 assessing a preschooler who has a facial laceration.
The nurse should identify which of the following findings as a potential
indication ofchild 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 to teach about dietary management to a client who
hasCrohn’s disease and an entero enteric fistula. Which of the following
nutrients should the nurse instruct the client to decrease in their diet?
Fiber
The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and
inflammation.
, • A nurse is caring for a client 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 to initiate IV access for an older adult client. Which of
thefollowing sites should the nurse select when initiating the IV for the client?
Radial vein of the inner arm.
This site will have adequate subcutaneous tissue
• 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
arisk 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 they will promote bone health by
increasingcalcium 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 the following interventions
should the nurse identify as the priority?
Initiate transmission-based precautions
When using the urgent versus 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 client who has a clogged percutaneous
gastrostomyfeeding 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, the nurse should attempt to
flush oraspirate the client’s tube to remove the clog.
ASSESSMENT 2019 B
• .A nurse is assessing a client who received 2 units of packed RBCs 48 hours
ago. Which of the following findings should indicate to the nurse that the
therapyhas been effective?
Hemoglobin 14.9 g/dl
The nurse should identify that packed RBCs are administered to clients who have a
decreased level of hemoglobin or hematocrit. This hemoglobin 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
ofthe following clients should the nurse recommend for treatment first?
A middle adult client who has unstable vital signs.
Using the stable versus unstable approach to client care, the nurse should
recommend priority treatment for the client who has unstable vital signs because this
client requires immediate treatment to reduce the risk of further injury or possible
death.
• A nurse is caring for a client who has fluid volume overload. Which of
thefollowing tasks should the nurse delegate to 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 to 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
theamount in grams the nurse should administer?
18 g
• A nurse is conducting a physical examination for an adolescent and
isassessing the range of motion of the legs. Which 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 client 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.
Whichof the following findings should the nurse expect?
Nuchal rigidity
This is a manifestation of bacterial meningitis.
• A nurse is assessing a newborn’s heart rate. Which of the following
actionsshould the nurse take?
Auscultate the apical pulse at least 1 min.
The nurse should auscultate the apical pulse to obtain an accurate assessment of
heartrate 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 to 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 assessing a preschooler who has a facial laceration.
The nurse should identify which of the following findings as a potential
indication ofchild 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 to teach about dietary management to a client who
hasCrohn’s disease and an entero enteric fistula. Which of the following
nutrients should the nurse instruct the client to decrease in their diet?
Fiber
The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and
inflammation.
, • A nurse is caring for a client 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 to initiate IV access for an older adult client. Which of
thefollowing sites should the nurse select when initiating the IV for the client?
Radial vein of the inner arm.
This site will have adequate subcutaneous tissue
• 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
arisk 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 they will promote bone health by
increasingcalcium 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 the following interventions
should the nurse identify as the priority?
Initiate transmission-based precautions
When using the urgent versus 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 client who has a clogged percutaneous
gastrostomyfeeding 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, the nurse should attempt to
flush oraspirate the client’s tube to remove the clog.
