ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?
- A. A client who has urolithiasis and reports severe ankle pain extending toward the abdomen
- B. A client who has acute cholecystitis and reports abdominal pain radiating to the right shoulder
- C. A client who has had a total knee arthroplasty, is 1 day postoperative, and reports a pain level of 8 on a 0 to 10 pain scale
- D. A client who has a fractured femur and reports sudden sharp chest pain
Correct answer: D
Rationale: The correct answer is D because a client with a fractured femur and sudden chest pain may be experiencing a pulmonary embolism, which requires immediate assessment. Choice A is incorrect because although severe pain is present, it is more indicative of musculoskeletal issues related to urolithiasis rather than a life-threatening condition. Choice B, related to acute cholecystitis, is less urgent than choice D as the pain radiating to the right shoulder is a common symptom but does not indicate an immediate life-threatening situation. Choice C, regarding a client post-total knee arthroplasty with a pain level of 8, is important but not as urgent as a potential pulmonary embolism in choice D.
2. Which action by the nurse will help reduce the risk of venous thromboembolism (VTE) in a postoperative patient?
- A. Encourage early ambulation and leg exercises.
- B. Apply compression stockings to the patient's legs.
- C. Administer anticoagulants as prescribed.
- D. Elevate the patient's legs to promote circulation.
Correct answer: A
Rationale: The correct answer is to encourage early ambulation and leg exercises. By promoting early ambulation and leg exercises, blood flow is enhanced, reducing the risk of venous thromboembolism (VTE) in postoperative patients. Choice B, applying compression stockings, helps prevent VTE but is not as effective as early ambulation and exercises. Choice C, administering anticoagulants, is important in VTE prevention but does not directly address improving circulation through physical activity. Choice D, elevating the patient's legs, may be beneficial for circulation in specific cases but is not as effective in preventing VTE as early ambulation and leg exercises.
3. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?
- A. Positioning the patient in a prone position
- B. Monitoring vital signs and lung sounds
- C. Preparing for mechanical ventilation
- D. Administering supplemental oxygen
Correct answer: A
Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.
4. A healthcare professional is reviewing the lab results of a client with liver disease. Which finding requires immediate intervention?
- A. Elevated bilirubin levels
- B. Low albumin levels
- C. Elevated ammonia levels
- D. Low hemoglobin levels
Correct answer: C
Rationale: Elevated ammonia levels in a client with liver disease can lead to hepatic encephalopathy, requiring immediate intervention. Ammonia is a neurotoxin that can cause cognitive impairment and altered mental status. Elevated bilirubin levels (Choice A) are common in liver disease but do not require immediate intervention. Low albumin levels (Choice B) and low hemoglobin levels (Choice D) are also common in liver disease but do not pose an immediate threat compared to elevated ammonia levels.
5. A patient is being treated for dehydration. Which lab result would support the diagnosis?
- A. Elevated hemoglobin
- B. Low sodium level
- C. High white blood cell count
- D. Elevated BUN
Correct answer: D
Rationale: Elevated BUN levels are a characteristic finding in dehydration due to reduced kidney perfusion and increased reabsorption of urea. Hemoglobin levels might be elevated in conditions like polycythemia vera, not directly related to dehydration. A low sodium level could be seen in conditions like hyponatremia. A high white blood cell count is more indicative of infection or inflammation rather than dehydration.
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