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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. 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.
2. A patient is receiving discharge teaching for esophageal cancer and starting radiation therapy. What instruction should the healthcare provider include?
- A. Remove dye markings after each radiation treatment
- B. Apply a warm compress to the irradiated site
- C. Wear clothing over the area of radiation treatment
- D. Use a washcloth to bathe the treatment area
Correct answer: C
Rationale: The correct instruction for a patient starting radiation therapy for esophageal cancer is to wear clothing over the area of radiation treatment. This helps to prevent irritation and protect the skin. Removing dye markings after each treatment (choice A) is unnecessary and not typically part of the patient's self-care. Applying a warm compress (choice B) can exacerbate skin irritation caused by radiation. Using a washcloth to bathe the treatment area (choice D) can potentially irritate the skin further, making it important to avoid.
3. A nurse is providing teaching for a client who is prescribed enoxaparin for DVT prevention. What is an appropriate action by the nurse?
- A. Expel the air bubble from the prefilled syringe
- B. Massage the injection site to distribute the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct answer: C
Rationale: The correct action for a nurse when administering enoxaparin for DVT prevention is to inject the medication into the lateral abdominal wall. This is the recommended site for enoxaparin administration. Expelling the air bubble is unnecessary and may lead to a dosage error. Massaging the injection site is not recommended as it can cause bruising. Administering an NSAID for injection site discomfort is not necessary as discomfort should be minimal and transient.
4. A nurse is caring for a client with hepatic encephalopathy. Which food selection indicates an understanding of dietary teaching?
- A. Cottage cheese
- B. Tuna salad
- C. Rice with black beans
- D. Three-egg omelet
Correct answer: C
Rationale: The correct answer is C: 'Rice with black beans.' Clients with hepatic encephalopathy should limit animal proteins due to their high ammonia content, which can exacerbate symptoms. Plant-based proteins like beans are preferred as they help reduce ammonia levels. Choices A, B, and D contain animal proteins that are not ideal for clients with hepatic encephalopathy.
5. A client is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
- A. Respiratory rate of 12/min
- B. Diminished deep tendon reflexes
- C. Urine output 40 mL/hr
- D. Systolic blood pressure of 140 mm Hg
Correct answer: B
Rationale: Diminished deep tendon reflexes are a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to decreased reflexes. Respiratory rate of 12/min, urine output 40 mL/hr, and systolic blood pressure of 140 mm Hg are not specific findings of magnesium toxicity. Respiratory depression, oliguria, and hypotension are more concerning signs that require immediate attention.
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