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Ati rn capstone proctored post assessment proctored exam
Ati rn capstone proctored post assessment proctored exam
Total Questions : 69
Showing 10 questions Sign up for moreA nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?
Explanation
Choice A reason: Massaging the legs of a client with DVT is contraindicated due to the risk of dislodging a thrombus, which could result in a pulmonary embolism. This action increases the risk of embolic events and must be avoided.
Choice B reason: Antiembolic stockings should be removed at least once per shift (every 8 hours) to assess skin integrity and promote circulation. Leaving them on for 24 hours without removal can lead to skin breakdown and impaired perfusion.
Choice C reason: Measuring the legs with a tape measure ensures the correct stocking size is selected. Proper sizing is essential for effective compression therapy, which helps prevent clot propagation and promotes venous return.
Choice D reason: Folding the stockings at the top can create a tourniquet effect, compromising circulation and increasing the risk of venous stasis. Stockings should be properly fitted and not altered in a way that impairs their function.
A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?
Explanation
Choice A reason: Repositioning the NG tube may be necessary if placement is incorrect, but it does not address the cause of hyperosmolar dehydration, which is related to the concentration and rate of the formula.
Choice B reason: Hyperosmolar dehydration occurs when the formula is too concentrated, pulling fluid into the GI tract and leading to systemic fluid loss. Diluting the formula with water reduces its osmolarity and helps prevent further dehydration.
Choice C reason: Increasing the rate of formula delivery can exacerbate hyperosmolar dehydration by overwhelming the GI tract’s absorptive capacity. Slower rates and diluted formulas are preferred in such cases.
Choice D reason: Switching to a lactose-free formula is appropriate for clients with lactose intolerance, but it does not address the osmolarity issue causing dehydration. Osmolarity, not lactose content, is the primary concern here.
A nurse is providing teaching to a guardian of a child who has ADHD. Which of the following strategies should the nurse suggest to improve the child's ability to concentrate?
Explanation
Choice A reason: Frequently varying scheduled activities can be overstimulating and reduce the child’s ability to focus. Children with ADHD benefit from consistent routines and structured environments.
Choice B reason: While handwriting may support memory retention, it does not necessarily improve concentration. The method of writing should be tailored to the child’s strengths and learning style.
Choice C reason: Completing homework in an area with minimal distractions is a proven strategy for improving focus in children with ADHD. A quiet, organized space helps reduce sensory overload and supports sustained attention.
Choice D reason: Encouraging reading during outdoor activity periods may isolate the child and reduce opportunities for physical activity, which is beneficial for attention regulation in ADHD. Structured breaks are important.
A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?
Explanation
Choice A reason: Administering a glycerin suppository is a routine, non-invasive task that can be safely delegated to an AP under nurse supervision. It does not require advanced clinical judgment or sterile technique.
Choice B reason: Rescue breathing is an emergency intervention requiring immediate clinical assessment and skill. This task should be performed by licensed personnel trained in resuscitation protocols.
Choice C reason: Providing home care instructions involves education and assessment, which fall within the scope of practice of a licensed nurse. APs are not qualified to deliver discharge teaching or care planning.
Choice D reason: Suctioning a newly inserted tracheostomy is a complex procedure requiring sterile technique and airway assessment. This task must be performed by a licensed nurse or respiratory therapist.
A nurse in a pediatric clinic is assessing a toddler at a well-child checkup. After reviewing the child's current medical record, which of the following interventions should the nurse expect the provider to prescribe?
Explanation
Choice A reason: Iron supplementation is commonly prescribed for toddlers who show signs of iron deficiency anemia, which is prevalent in this age group due to rapid growth and dietary limitations. Routine screening often reveals low hemoglobin or hematocrit levels, prompting preventive or corrective supplementation.
Choice B reason: Blood transfusion is reserved for severe anemia or acute blood loss. It is not a standard intervention during a well-child visit unless there is a critical indication, which would be evident in the clinical presentation or lab results.
Choice C reason: Antibiotic therapy is indicated for active infections, not as a preventive measure during routine checkups. Without signs of infection, prescribing antibiotics would be inappropriate and contribute to antimicrobial resistance.
Choice D reason: A protective environment is typically prescribed for immunocompromised individuals, such as those undergoing chemotherapy or with severe immunodeficiency. It is not relevant for a healthy toddler during a routine assessment.
A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over-the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?
Explanation
Choice A reason: Magnesium supplements are generally safe with spironolactone unless the client has renal impairment. They do not directly interact with the drug’s mechanism of action or pose a significant risk of electrolyte imbalance.
Choice B reason: Potassium should be avoided because spironolactone is a potassium-sparing diuretic. Concurrent use of potassium supplements increases the risk of hyperkalemia, which can lead to cardiac arrhythmias and other serious complications.
Choice C reason: Iron does not interact significantly with spironolactone. While iron levels should be monitored in certain populations, it is not contraindicated with this medication.
Choice D reason: Calcium supplementation is not contraindicated with spironolactone, although excessive intake may contribute to other metabolic imbalances. It does not pose the same immediate risk as potassium.
A nurse is assessing a client who is postpartum and has developed endometritis. Which of the following findings should the nurse expect?
Explanation
Choice A reason: Chills are a classic symptom of endometritis, which is an infection of the uterine lining. It typically presents with fever, uterine tenderness, foul-smelling lochia, and systemic signs of infection such as chills.
Choice B reason: Back pain is not a hallmark symptom of endometritis. While discomfort may be present, it is more commonly associated with musculoskeletal strain or epidural-related issues postpartum.
Choice C reason: Agitation is not a typical symptom of endometritis. It may occur in cases of severe infection or sepsis, but it is not a primary diagnostic indicator.
Choice D reason: Bradycardia is not expected in endometritis. In fact, tachycardia is more common due to the systemic inflammatory response and fever.
A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station. Which of the following interventions should the nurse implement?
Explanation
Choice A reason: A pudendal nerve block is typically used during the second stage of labor for perineal pain relief. It is not appropriate during the latent phase and does not address back pain caused by fetal positioning.
Choice B reason: A warm bath may provide general comfort but is less effective for targeted relief of back pain during contractions. It is more appropriate during active labor or for relaxation.
Choice C reason: Counterpressure applied to the lower back during contractions is a well-established non-pharmacologic intervention for relieving back labor pain, especially when the fetus is in an occiput posterior position.
Choice D reason: Terbutaline is a tocolytic used to stop preterm labor. It is not indicated for pain management during the latent phase and could interfere with normal labor progression.
A nurse is caring for a client who is 12 hours postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?
Explanation
Choice A reason: Rewrapping the bandage in a circular pattern can impair circulation and increase the risk of edema. A figure-eight or diagonal wrapping technique is preferred to promote venous return and shape the residual limb for prosthesis fitting.
Choice B reason: Using an overbed trapeze allows the client to reposition independently, which promotes mobility, prevents complications such as pressure injuries, and supports postoperative recovery. It also reduces strain on the surgical site.
Choice C reason: An air mattress may be used for clients at high risk of pressure injuries, but it is not a standard intervention for all postoperative amputation clients unless additional risk factors are present.
Choice D reason: Turning every 4 hours is insufficient for postoperative care. Standard practice recommends repositioning every 2 hours to prevent pressure ulcers and promote circulation.
A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?
Explanation
Choice A reason: Once mixed, regular and NPH insulin should be administered promptly—within 5 to 15 minutes—to ensure stability and effectiveness. Delayed administration can alter absorption rates and glycemic control.
Choice B reason: Air should be injected into the NPH vial first, then into the regular insulin vial. This prevents contamination of the regular insulin with NPH, which could affect its pharmacokinetics.
Choice C reason: Regular insulin should be withdrawn before NPH insulin to avoid contaminating the regular insulin vial with the longer-acting NPH insulin. This preserves the integrity of both medications.
Choice D reason: Insulin vials should be gently rolled, not shaken. Shaking can denature the protein structure, especially in NPH insulin, leading to inconsistent dosing and reduced efficacy.
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