ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. A healthcare professional is planning care for a client who is scheduled for a lumbar puncture. Which of the following actions should the healthcare professional include?
- A. Restrict the client's fluid intake for 4 hours following the procedure
- B. Apply cold compresses to the puncture site after the procedure
- C. Instruct the client to increase oral fluid intake after the procedure
- D. Keep the client in a prone position for 12 hours after the procedure
Correct answer: C
Rationale: The correct action to include in caring for a client scheduled for a lumbar puncture is to instruct the client to increase oral fluid intake after the procedure. Increasing oral fluid intake helps replace cerebrospinal fluid lost during the lumbar puncture and reduces the risk of headaches. Restricting fluid intake (Choice A) is not recommended as it can lead to dehydration. Applying cold compresses (Choice B) is not necessary after a lumbar puncture. Keeping the client in a prone position for 12 hours (Choice D) is not required after a lumbar puncture and can cause discomfort and complications.
2. A client with tuberculosis is about to start combination drug therapy. Which of the following medications should the nurse plan to administer? (SATA)
- A. Acyclovir
- B. Pyrazinamide
- C. Isoniazid
- D. Rifampin
Correct answer: B
Rationale: The correct answer is B: Pyrazinamide. In the treatment of tuberculosis, a combination drug therapy is usually employed. Pyrazinamide and rifampin are two key drugs used in this regimen. Acyclovir is an antiviral medication used for herpes infections, not for tuberculosis. Isoniazid is another medication used in tuberculosis treatment, but in this case, the question asked for medications to administer, and the correct choices should be those commonly used in tuberculosis combination therapy.
3. A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?
- A. Monitor the client's intake and output every 6 hours
- B. Administer furosemide to the client
- C. Check the client's IV infusion every 8 hours
- D. Offer the client 240 ml (8 oz) of oral fluids every 4 hours
Correct answer: D
Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.
4. A healthcare professional in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms?
- A. Cromolyn via metered dose inhaler
- B. Budesonide via dry powder inhaler
- C. Montelukast orally
- D. Albuterol via jet nebulizer
Correct answer: D
Rationale: Albuterol via jet nebulizer is the correct choice in this scenario as it is a short-acting bronchodilator that quickly relieves bronchospasm during an asthma exacerbation. Cromolyn (Choice A) is a mast cell stabilizer used for prevention, not quick relief. Budesonide (Choice B) is an inhaled corticosteroid used for long-term control, not for acute symptom relief. Montelukast (Choice C) is a leukotriene receptor antagonist used for maintenance therapy, not for immediate symptom relief during an exacerbation.
5. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notices clots in the client's urinary catheter and decreased urinary output. Which of the following actions should the nurse take?
- A. Administer an antispasmodic
- B. Irrigate the catheter with 0.9% sodium chloride irrigation
- C. Apply gentle manual pressure to the bladder
- D. Clamp the catheter tubing
Correct answer: B
Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation. This action helps clear the clots in the catheter and restore proper urine flow after a TURP. Administering an antispasmodic (Choice A) is not the appropriate action for clots in the catheter and decreased urinary output. Applying gentle manual pressure to the bladder (Choice C) or clamping the catheter tubing (Choice D) could potentially worsen the situation by causing bladder distention or preventing urine drainage.
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