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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client in respiratory distress who is on oxygen is being cared for by a nurse. What is the most appropriate short-term goal?
- A. Nasal cannula remains in place
- B. Client completes morning care
- C. Client verbalizes breathing improvement after lunch
- D. Client maintains oxygen saturation of 90% during the shift
Correct answer: D
Rationale: The correct answer is D because maintaining oxygen saturation of 90% is a specific, measurable short-term goal that ensures adequate oxygenation. Choice A is not a goal focused on the client's physiological status but rather on the equipment. Choice B is related to activities of daily living and does not address the respiratory distress issue. Choice C is subjective and may not reflect the actual physiological improvement in the client's condition.
2. A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?
- A. Increase calcium intake
- B. Provide a diet high in potassium
- C. Restrict protein intake
- D. Increase fluid intake
Correct answer: C
Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.
3. A charge nurse is teaching a new nurse how to clean surfaces contaminated with blood. Which agent should the charge nurse include in the teaching?
- A. Hydrogen peroxide
- B. Chlorhexidine
- C. Isopropyl alcohol
- D. Chlorine bleach
Correct answer: D
Rationale: Chlorine bleach is the most appropriate agent for disinfecting surfaces contaminated with blood. It is effective in killing a wide range of pathogens, including viruses. Hydrogen peroxide (Choice A) is not as effective as chlorine bleach for bloodborne pathogen disinfection. Chlorhexidine (Choice B) and isopropyl alcohol (Choice C) are more commonly used for skin antisepsis rather than surface disinfection, making them less suitable options in this scenario.
4. A client with preeclampsia is receiving magnesium sulfate intravenously. What action should the nurse take if the client develops toxicity?
- A. Position the client supine
- B. Prepare an IV bolus of dextrose 5%
- C. Administer calcium gluconate IV
- D. Administer methylergonovine IM
Correct answer: C
Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote as it helps reverse the effects. Positioning the client supine (Choice A) may not directly address magnesium sulfate toxicity. Administering dextrose 5% (Choice B) is not the correct intervention for magnesium sulfate toxicity. Methylergonovine IM (Choice D) is used to manage postpartum hemorrhage, not magnesium sulfate toxicity.
5. A client had a pituitary tumor removed. Which of the following findings requires further assessment?
- A. Glasgow scale score of 15
- B. Blood drainage on dressing measuring 3 cm
- C. Report of dry mouth
- D. Urinary output greater than fluid intake
Correct answer: D
Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.
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