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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is planning care for a newly admitted adolescent with bacterial meningitis. What intervention should the nurse include?
- A. Initiate droplet precautions
- B. Assist the client to a supine position
- C. Perform a Glasgow Coma Scale every 24 hours
- D. Recommend prophylactic acyclovir for the client's family
Correct answer: A
Rationale: The correct intervention for a newly admitted adolescent with bacterial meningitis is to initiate droplet precautions. Bacterial meningitis is highly contagious, and droplet precautions are necessary to prevent the spread of infection. Assisting the client to a supine position (Choice B) is not directly related to managing bacterial meningitis. Performing a Glasgow Coma Scale every 24 hours (Choice C) may be important to assess the client's neurological status but is not the priority intervention in preventing the spread of infection. Recommending prophylactic acyclovir for the client's family (Choice D) is not a standard practice in the care of a patient with bacterial meningitis.
2. A client with hepatic encephalopathy is being cared for by a nurse. Which food selection indicates the client understands dietary teaching?
- A. A sandwich and milkshake
- B. Rice with black beans
- C. Cottage cheese and tuna lettuce
- D. Three-egg omelet with low-sodium ham
Correct answer: B
Rationale: For clients with hepatic encephalopathy, foods high in protein like cottage cheese and tuna should be avoided. Plant-based protein sources like beans are recommended due to their lower ammonia production during digestion. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they include high-protein or high-sodium foods that can worsen the condition of hepatic encephalopathy.
3. A nurse is planning care for a client with a sealed radiation implant. Which intervention should the nurse implement?
- A. Remove dirty linens after double-bagging them
- B. Wear a dosimeter badge in the client’s room
- C. Limit visitors to 1 hour per day
- D. Ensure family remains 3 feet away from the client
Correct answer: B
Rationale: The nurse should wear a dosimeter badge to monitor radiation exposure when caring for a client with a sealed radiation implant.
4. A nurse is using Naegele’s rule to calculate the expected delivery date for a client whose last menstrual period was in October. What is the expected date?
- A. 711
- B. 1011
- C. 411
- D. 1211
Correct answer: A
Rationale: Using Naegele’s rule, to calculate the expected delivery date, you add one year, subtract three months, and add seven days to the first day of the last menstrual period. If the last menstrual period was in October, adding one year gives October of the following year. Subtracting three months gives July, and adding seven days gives the expected delivery date of July 11th. Therefore, the correct answer is 711. Choice B (1011) is incorrect as it doesn't follow Naegele’s rule calculations. Choices C (411) and D (1211) are also incorrect as they do not align with the correct application of Naegele’s rule.
5. A nurse is planning care for four clients. Which client is the highest priority?
- A. Client with dry, black eschar on the heel
- B. Client wearing an arm cast and reporting numb fingers
- C. Client with reddened skin around the coccyx
- D. Client with frequent incontinence
Correct answer: B
Rationale: The correct answer is B because numb fingers indicate neurovascular compromise, which can lead to serious complications if not addressed promptly. The priority in this situation is to assess and address any circulation issues affecting the extremity. Choices A, C, and D are of concern but not as immediate as neurovascular compromise, which requires urgent attention to prevent further complications.
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