RN ATI Capstone Proctored Comprehensive Assessment 2019 B/ ATI
Comprehensive 2019 B
A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is
the nurse’s priority? Assist with deep breathing and coughing
A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of
the following statements by the client as a constructive use of a defense mechanism? “I told my
doctor that I would like to start a support group for other women who are sick in my community”
A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the
following actions should the nurse take? Monitor the client’s mouth every 8 hr
A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following
areas should the nurse assess for manifestations of HD? C
The nurse should assess the infant’s abdomen for distention and visible peristalsis, which are
manifestations of HD
A nurse at a mental health clinic is caring for four clients. The nurse should recognize the following
clients is using dissociation as a defense mechanism? A client who was abused as a child describes
the abuse as if it happened to someone else
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse
should instruct the client to monitor for which of the following findings as a manifestation of
hypoglycemia? irritability
A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize
that which of the following clients is effectively using sublimation as a defense mechanism? A client
who channels their energy into a new hobby following the loss of their job
A hospice nurse is consulting with a client and her family about receiving home services. Which of
the following statements should the nurse identify as an indication that the family understands home
hospice care? “We can expect the hospice nurse to provide support for us after our mother’s
death”
A nurse is caring for a client who has active tuberculosis. Which of the following actions should the
nurse take? Assign the client to a private room with negative air pressure
A nurse is providing teaching to a client who is at 24 weeks of gestation and is schedule for a 3 hour oral
glucose tolerance test. Which of the following instructions should the nurse include in the teaching?
“You will need to fast the night before the test”
A nurse on a pediatric unit has received 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 for an
appendectomy and experienced sudden relief from pain
A nurse in a community center is providing an education session to a group of clients about
ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include
in the teaching?Abdominal bloating
A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The
client suddenly becomes restless and reports feeling lightheaded. Which of the following actions
should the nurse take? Check the client’s oxygen saturation level
A nurse is working in an emergency department is triaging four clients. Which of the following
clients should the nurse recommend for treatment first? A middle adult client who has
unstable vital signs
A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in
place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which of
the following instructions should the nurse include in the teaching? Use a three-point gait
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should
the nurse select when initiating the IV for this client? Radial vein of the inner arm
A nurse is planning to delegate client care tasks to an AP. Which of the following tasks should the nurse
plan to delegate to the AP? Perform gastrostomy feedings through a client’s established
gastrostomy tube
A nurse is caring for a newborn immediately after delivery. Which of the following interventions
should the nurse implement to prevent heat loss by conduction? Use a protective cover on the
scale when weighing the infant
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following
laboratory tests should the nurse review prior to adjusting the client’s heparin? aPTT
A nurse administers an incorrect dose of medication to a client. The nurse recognized the error
immediately and completes and incident report. Which of the following facts related to the
incident should the nurse document in the client’s medical record? Time the medication was
given
A nurse is providing education to the parent of a school age child who has asthma. Which of the
following statements by the parent indicates an understanding of the teaching? “I will make sure my
child receives a yearly influenza immunization”
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling
off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider?
Apply a cold pack to the client’s ankle for 30 min every hour
A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline. Which of
the following findings should the nurse identify as an adverse effect of the medication? Blurred vision
A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive
therapy (ECT). The client states to the nurse “I’m not sure about this now. I’m afraid it’s too risky.”
Which of the following responses should the nurse make? “You have the right to change your mind
about the procedure at any time”
A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who
has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should
administer?
18 g
A nurse is preparing to administer an IM injection to a client who is obese. Which of the
following actions should the nurse plan to take? Use the ventrogluteal site
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the
following instructions should the nurse include in the teaching? Wear clothing made with cotton fabrics
while oxygen is in use
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden
infant death syndrome (SIDS). Which of the following guardian statements indicates an
understanding of the teaching? “I will not allow anyone to smoke near my baby”
A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus.
Which of the following medications should the nurse expect to administer? Oxytocin
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The
client tells the nurse that they would like to go home to be with family and loved ones. Which of the
following actions should the nurse take? Make a referral for social services
A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of
the following actions should the nurse take first? Change the position of the client
A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of
the following interventions should the nurse include in the plan? Support the client’s left arm on a
pillow while sitting
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
A charge nurse is providing an educational session about infection control for a group of staff
nurses. Which of the following statements by one of the staff nurses indicated an understanding of
isolation precautions? “A client who requires airborne precautions should be placed in a negative
pressure airflow room”
A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of
the following food recommendations should the nurse make? Broccoli
Yogurt
Cream cheese
Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli, yogurt, and
cream cheese do not contain tyramine.
A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the
nurse expect? Acute confusion
An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy,
and anorexia.