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RN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT 2019 B LATEST UPDATED 2024 • . A nurse isassessing a school-aged child who has bacterial meningitis. Whichof the following findings should the nurse expect? Nuchal rigidity Thisisa manifestationofbacterial meningitis. • A nurse isassessing a newborn’s heart rate. Which of the following actionsshould the nurse take? Auscultatetheapical pulseat least 1 min. Thenurseshould auscultatetheapical pulsetoobtain anaccurate assessment of heartrate and rhythm. Auscultation of a newborn’s heart sounds can be difficult because of therapid rateand thetransmission of respiratory sounds. • A nurse is preparing to assist with athoracentesis foraclient who has pleurisy.The nurse should plan to perform which of the following actions? Instruct theclient toavoid coughing duringtheprocedure. It is important for thenursetoremind theclient toavoid coughing and toliestill during athoracentesis toavoid puncturing thepleura. • 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 of child sexualabuse? Thechildexhibitsdiscomfort while walking. Thenurseshouldidentify this finding asapotential indication of childsexual 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 inflammation. following nutrients should the nurse instruct the client to decrease in their diet? Fiber Thenurseshould instruct theclient toconsumealow-fiber diet toreducediarrhea and • A nurse iscaring fora client who has a prescription for acontinuous passivemotion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? Turn off the CPM machine during mealtime. Thispromotesclientcomfort anddietary intake. • •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? Hemoglobin14.9 g/dl Thenurseshouldidentify thatpacked RBCs areadministeredtoclients whohaveadecreased level of hemoglobin or hematocrit. This hemoglobin level is within the expected reference range of 14to 18 g/dl for males and 12to16 g/dl for females, •.A nurse working in a n emergency department is triaging fourclients. Which ofthe following clients should the nurse recommend for treatment first? A middleadultclient whohas unstablevital signs. Using the stable versus unstable approach to client care, the nurse should indicating the therapy has been effective. recommendpriority treatment for theclient who has unstablevital signs becausethis client requires • A nurse iscaring fora client who has fluid volume overload. Which of thefollowing tasks should the nurse delegate to the CNA? Measuretheclient’sdaily weight It is withinthe CNAs rangeof functionto measureaclient’s daily weight, sothenurseshould delegatethis task tothem. • 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 is assessing the range of motion of the legs. Which of the following imagesindicates the adolescent is abducting the hip joint? Inthecorrect image, theadolescent is abduction thehipjointby moving theleg awayfrom the midline of the body. • A nurse iscaring fora client who has hyperthyroidism. Which of the followingfindings should the nurse expect? Tremors Tremorsarea manifestationof hyperthyroidism,along withtachycardia, diaphoresis,weight loss, insomnia, and exophthalmia. immediate treatment to reduce the risk of further injury or possible death. 2 3 • A nurse is preparing to initiate IV access for an older adultclient. Which of thefollowing sites should the nurse select when initiating the IV for the client? Radial veinof theinnerarm. This site willhaveadequatesubcutaneous tissue • A nurse is developing a client education program a bout osteoporosis for olderadultclients. The nurse should include which of the following variables asarisk factor for osteoporosis? Sedentary lifestyle. This is a risk factor for osteoporosis. The nurse should encourage older adult clients to engagein weight-bearing exercisesbecausethey will promotebonehealthbyincreasingcalcium and phosphorus levels. • A nurse in an ED is caring for achild who has afever and fluid-filled vesicleson the trunk and extremities. Which of the following interventions should the nurse identifyas the priority? Initiatetransmission-basedprecautions 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. Thechild most likelyhas varicella.Therefore, the nurseshould isolatethechild toprevent thespread of theinfection. • A nurse is caring fora client who has aclogged percutaneous gastrostomyfeeding tube. Which of the following actions should the nurse take first? Changetheposition of theclient. 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, whichcanleadtoclogging. If this methodis unsuccessful, thenurseshould attempt toflush oraspiratethe client’s tube toremovetheclog. • A home health care nurse is developing a teaching plan for aclient who has anew ileostomy. Which of the folRN ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT 2019 B LATEST UPDATED 2024 • . A nurse isassessing a school-aged child who has bacterial meningitis. Whichof the following findings should the nurse expect? Nuchal rigidity Thisisa manifestationofbacterial meningitis. • A nurse isassessing a newborn’s heart rate. Which of the following actionsshould the nurse take? Auscultatetheapical pulseat least 1 min. Thenurseshould auscultatetheapical pulsetoobtain anaccurate assessment of heartrate and rhythm. Auscultation of a newborn’s heart sounds can be difficult because of therapid rateand thetransmission of respiratory sounds. • A nurse is preparing to assist with athoracentesis foraclient who has pleurisy.The nurse should plan to perform which of the following actions? Instruct theclient toavoid coughing duringtheprocedure. It is important for thenursetoremind theclient toavoid coughing and toliestill during athoracentesis toavoid puncturing thepleura. • 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 of child sexualabuse? Thechildexhibitsdiscomfort while walking. Thenurseshouldidentify this finding asapotential indication of childsexual 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 inflammation. following nutrients should the nurse instruct the client to decrease in their diet? Fiber Thenurseshould instruct theclient toconsumealow-fiber diet toreducediarrhea and • A nurse iscaring fora client who has a prescription for acontinuous passivemotion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? Turn off the CPM machine during mealtime. Thispromotesclientcomfort anddietary intake. • •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? Hemoglobin14.9 g/dl Thenurseshouldidentify thatpacked RBCs areadministeredtoclients whohaveadecreased level of hemoglobin or hematocrit. This hemoglobin level is within the expected reference range of 14to 18 g/dl for males and 12to16 g/dl for females, •.A nurse working in a n emergency department is triaging fourclients. Which ofthe following clients should the nurse recommend for treatment first? A middleadultclient whohas unstablevital signs. Using the stable versus unstable approach to client care, the nurse should indicating the therapy has been effective. recommendpriority treatment for theclient who has unstablevital signs becausethis client requires • A nurse iscaring fora client who has fluid volume overload. Which of thefollowing tasks should the nurse delegate to the CNA? Measuretheclient’sdaily weight It is withinthe CNAs rangeof functionto measureaclient’s daily weight, sothenurseshould delegatethis task tothem. • 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 is assessing the range of motion of the legs. Which of the following imagesindicates the adolescent is abducting the hip joint? Inthecorrect image, theadolescent is abduction thehipjointby moving theleg awayfrom the midline of the body. • A nurse iscaring fora client who has hyperthyroidism. Which of the followingfindings should the nurse expect? Tremors Tremorsarea manifestationof hyperthyroidism,along withtachycardia, diaphoresis,weight loss, insomnia, and exophthalmia. immediate treatment to reduce the risk of further injury or possible death. 2 3 • A nurse is preparing to initiate IV access for an older adultclient. Which of thefollowing sites should the nurse select when initiating the IV for the client? Radial veinof theinnerarm. This site willhaveadequatesubcutaneous tissue • A nurse is developing a client education program a bout osteoporosis for olderadultclients. The nurse should include which of the following variables asarisk factor for osteoporosis? Sedentary lifestyle. This is a risk factor for osteoporosis. The nurse should encourage older adult clients to engagein weight-bearing exercisesbecausethey will promotebonehealthbyincreasingcalcium and phosphorus levels. • A nurse in an ED is caring for achild who has afever and fluid-filled vesicleson the trunk and extremities. Which of the following interventions should the nurse identifyas the priority? Initiatetransmission-basedprecautions 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. Thechild most likelyhas varicella.Therefore, the nurseshould isolatethechild toprevent thespread of theinfection. • A nurse is caring fora client who has aclogged percutaneous gastrostomyfeeding tube. Which of the following actions should the nurse take first? Changetheposition of theclient. 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, whichcanleadtoclogging. If this methodis unsuccessful, thenurseshould attempt toflush oraspiratethe client’s tube toremovetheclog. • A home health care nurse is developing a teaching plan for aclient who has anew ileostomy. Which of the following instructions should the nurse include? Empty theappliance whenit isone-thirdtoone-half full. Theileostomy pouchshouldbeemptied whenit isone-thirdtoone-half full topreventstool leakage and skin irritation. lowing instructions should the nurse include? Empty theappliance whenit isone-thirdtoone-half full. Theileostomy pouchshouldbeemptied whenit isone-thirdtoone-half full topreventstool leakage and skin irritation.