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Ati rn capstone proctored comprehensive assessment A
Ati rn capstone proctored comprehensive assessment A
Total Questions : 80
Showing 10 questions Sign up for moreA nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Explanation
A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.
B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.
C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.
D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.
A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?
Explanation
A. Herpes zoster – This vaccine is recommended for adults 50 years and older to prevent shingles, a painful rash caused by reactivation of the varicella-zoster virus. Older adults are at increased risk for complications from shingles, making this an essential immunization for this age group.
B. Diphtheria, tetanus, and acellular pertussis (DTaP) – This vaccine is primarily for children younger than 7 years old. Instead, older adults should receive the Tdap or Td vaccine as a booster every 10 years.
C. Human papillomavirus (HPV) – The HPV vaccine is recommended primarily for adolescents and young adults up to 26 years old to prevent cervical and other cancers. It is not typically given to older adults.
D. Rotavirus – The rotavirus vaccine is given to infants, as this virus causes severe diarrhea in young children. It is not needed in older adults.
A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?
Explanation
A. Healthy weight – A BMI between 18.5 and 24.9 is classified as healthy. Since the client's BMI is 17.2, they do not fall within this range.
B. Overweight – Overweight is defined as a BMI between 25.0 and 29.9. The client's BMI of 17.2 is far below this range.
C. Underweight – A BMI below 18.5 is classified as underweight. Since the client's BMI is 17.2, they fall into this category. Clients with Crohn’s disease often experience malabsorption and weight loss, leading to a low BMI.
D. Obesity class 1 – Obesity is categorized as a BMI of 30.0 or higher. The client’s BMI is far below this classification.
A nurse in an acute mental health facility is teaching a client about the potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that he might feel lightheaded, but that it should not affect his memory. The nurse is demonstrating which of the following ethical principles?
Explanation
A. Beneficence – This principle refers to doing good for the client, such as providing effective care and promoting well-being. While the nurse is educating the client, this action is more about truthfulness than actively promoting well-being.
B. Fidelity – Fidelity refers to maintaining trust and keeping commitments to the client. While honesty builds trust, fidelity is more about keeping promises rather than providing truthful information.
C. Autonomy – Autonomy means respecting a client’s right to make decisions about their care. While education supports informed decision-making, the nurse’s focus in this scenario is on honesty rather than respecting autonomy.
D. Veracity – Veracity refers to truthfulness and honesty in communication. The nurse is providing accurate information about the side effects of transcranial magnetic stimulation, ensuring that the client has correct expectations.
A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first?
Explanation
A. Close the doors and windows on the unit – While containing the fire is important, it is not the first priority. Activating the fire alarm ensures facility-wide response and safety protocols.
B. Activate the fire alarm system – This is the first action because it alerts emergency responders and allows evacuation protocols to begin. Timely activation prevents the fire from spreading and ensures prompt intervention.
C. Obtain and use a fire extinguisher – Fire extinguishers are used only for small, contained fires and should be handled by trained personnel after activating the alarm.
D. Evacuate clients from the area – While evacuation is critical, activating the fire alarm ensures a coordinated evacuation plan rather than causing panic.
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take first?
Explanation
A. Close the doors and windows on the unit – While containing the fire is important, it is not the first priority. Activating the fire alarm ensures facility-wide response and safety protocols.
B. Activate the fire alarm system – This is the first action because it alerts emergency responders and allows evacuation protocols to begin. Timely activation prevents the fire from spreading and ensures prompt intervention.
C. Obtain and use a fire extinguisher – Fire extinguishers are used only for small, contained fires and should be handled by trained personnel after activating the alarm.
D. Evacuate clients from the area – While evacuation is critical, activating the fire alarm ensures a coordinated evacuation plan rather than causing panic.
A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?
Explanation
A. "I can expect my eyelids to be bruised after this procedure." – Bruising of the eyelids is not a typical postoperative effect of cataract surgery. The procedure is minimally invasive and does not cause significant trauma to surrounding tissues.
B. "I know the provider will replace the lens in my eyes during this procedure." – This is the correct statement. Cataract surgery involves removing the cloudy lens and replacing it with an artificial intraocular lens (IOL) to restore vision.
C. "I will see dark spots in my vision after this procedure." – Visual disturbances such as dark spots or floaters are not expected. Some clients may experience mild blurriness, but this should improve as the eye heals.
D. "I will receive general anesthesia for this procedure." – Cataract surgery is typically performed under local anesthesia with sedation, not general anesthesia. The client remains awake but does not feel pain.
A nurse on a medical-surgical unit is accepting a telephone prescription for a client who requires medication for insomnia. Which of the following actions should the nurse take?
Explanation
A. Repeat the complete prescription back to the provider – This is the correct action to ensure accuracy and prevent medication errors. The nurse must read back the prescription, including the medication name, dosage, route, and frequency, for verification.
B. Have a provider who is on site sign the prescription – The prescribing provider must sign the order within a specific timeframe, but this step occurs after verifying and documenting the prescription.
C. Have the unit secretary enter the prescription on the provider's order form – Only licensed personnel (nurses, pharmacists, or providers) can transcribe and verify medication orders. The unit secretary cannot enter prescriptions.
D. Verify the accuracy of the prescription with the pharmacist – The nurse should first confirm the order with the provider, not the pharmacist. The pharmacist’s role comes after the order is documented and entered.
A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?
Explanation
A. Place the client on an air mattress – While air mattresses help prevent pressure ulcers, they do not directly address mobility needs in the immediate postoperative period.
B. Rewrap the bandage every 8 hr in a circular pattern – The bandage should be reapplied more frequently (every 4–6 hr) using a figure-eight pattern to prevent restriction of circulation.
C. Turn the client every 4 hr while in bed – Clients should be turned at least every 2 hr to prevent pressure ulcers and improve circulation.
D. Instruct the client to use an overbed trapeze to move around in bed – This is the best intervention because it allows the client to reposition independently, reducing the risk of skin breakdown and enhancing mobility.
A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?
Explanation
A. Fold the stockings at the top if they are too long – Folding the stockings can create a tourniquet effect, restricting circulation and increasing the risk of complications.
B. Remove the stockings every 24 hr – Antiembolitic stockings should be removed at least every 8 hr to assess skin integrity and circulation, not just once per day.
C. Massage the legs before applying the stockings – Massaging the legs is contraindicated in clients with DVT because it can dislodge a clot, leading to a pulmonary embolism.
D. Measure the legs with a tape measure to determine stocking size – This is the correct action because improper fit can reduce effectiveness or impair circulation. The nurse should measure the client’s legs and select the appropriate size for optimal compression.
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