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Ati capstone fundamentals assessment
Total Questions : 49
Showing 10 questions, Sign in for moreA nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?
0800:
Client returned from a scheduled left-heart catheterization. The client is lying flat without complaints.
1000:
Client's partner reports that they noticed "blood on the sheets." Nurse observes there is bleeding around the catheter insertion site, and the pressure dressing has become dislodged. Nurse dons gloves and applies direct pressure to the wound. Provider notified, and a new hemostatic pressure dressing placed. Nurse removes gloves and notes a small amount of blood to the right upper hand.
1030:
- Temperature 37° C (98.6° F)
- Heart rate 69/min
- Respiratory rate 18/min
- Blood pressure 125/88 mm Hg
- Oxygen saturation 97% on room air
A nurse is caring for a client on a medical-surgical unit.
Complete the following sentence by using the list of options.
The nurse should
Explanation
Rationale:
After removing gloves, the nurse observed visible blood on the hand, which means handwashing with soap and water is required. Alcohol-based hand rub is not effective on visibly soiled hands, especially when blood or bodily fluids are present. Proper drying with a clean paper towel is the correct next step to complete hand hygiene.
Applying alcohol-based hand rub to visibly soiled hands is not recommended. Hand rubs are ineffective on visibly dirty or contaminated hands. Gloves are not a substitute for hand hygiene, regardless of the amount of blood.
A nurse is planning teaching about meditation for a client who reports feeling anxious. Which of the following statements should the nurse include in the teaching?
A nurse is completing an admission assessment for a client who has hearing loss. Which of the following actions should the nurse take?
1130:
Client reports shortness of breath. Client states "my asthma is acting up." The client reports they have taken their rescue inhaler at home this morning without improvement in symptoms.
Client is alert, appears mildly uncomfortable. Mucous membranes moist. Diffuse wheezing auscultated throughout lung fields. S1, S2 auscultated, no murmur. Skin warm and dry. Vital signs obtained. Provider notified of findings, prescriptions obtained. Albuterol nebulizer administered along with methylprednisolone.
1130:
- Albuterol nebulizer 2.5 mg stat
- Methylprednisolone 50 mg IV stat
1130:
- Temperature 37° C (98.6° F)
- Heart rate 60/min
- Respiratory rate 22/min
- Blood pressure 138/82 mm Hg
- Oxygen saturation 89% on 3L nasal cannula
1150:
- Temperature 37° C (98.6° F)
- Heart rate 98/min
- Respiratory rate 27/min
- Blood pressure 168/90 mm Hg
- Oxygen saturation 84% on 3L nasal cannula
1200:
Client re-evaluated following nebulizer treatment. Client appears anxious, hand tremor present. Mucous membranes cyanotic, clear rhinorrhea visible. Diffuse wheezing auscultated throughout lung fields. S1,S2 auscultated, no murmur. Skin warm and dry.
A nurse is caring for a client in the emergency department.
Click to highlight the findings that indicate client's condition is worsening. To deselect a finding, click on the finding again.
Physical Exam:
1200:
Client re-evaluated following nebulizer treatment. Client appears anxious, hand tremor present. Mucous membranes cyanotic, clear rhinorrhea visible. Diffuse wheezing auscultated throughout lung fields. S1,S2 auscultated, no murmur. Skin warm and dry.
Vital Signs
1150:
- Temperature 37° C (98.6" F)
- Heart rate 98/min
- Respiratory rate 27/min
- Blood pressure 168/90 mm Hg
- Oxygen saturation 84% on 3L nasal cannula
Explanation
Rationale:
Client appears anxious: Anxiety, in the context of respiratory distress, is often a sign of worsening hypoxia or hypercapnia. Clients with asthma may become anxious due to the sensation of breathlessness and air hunger. It also reflects increased sympathetic stimulation due to stress or rising carbon dioxide levels. This finding, in combination with physical signs of hypoxia, indicates the client is decompensating emotionally and physiologically.
Mucous membranes cyanotic: Cyanosis of the mucous membranes (lips, tongue) is a late and critical sign of hypoxemia. It reflects insufficient oxygenation of arterial blood, suggesting that the lungs are not effectively exchanging gases. In asthma, cyanosis signals severe airway obstruction, alveolar hypoventilation, or impending respiratory failure. This finding alone requires immediate escalation of care (e.g., high-flow oxygen, possible intubation).
Oxygen saturation 84% on 3L nasal cannula: An SpOâ‚‚ of 84% is dangerously low, even with supplemental oxygen, and indicates poor oxygen exchange. Normal SpOâ‚‚ is ≥95%. Asthma exacerbations are considered severe when SpOâ‚‚ drops below 90%, even on room air, and this client is already on 3 L/min of oxygen, meaning the lungs are failing to oxygenate. This is a red flag for respiratory failure or impending intubation.
Respiratory rate 27/min: An increasing respiratory rate suggests the client is working harder to breathe, compensating for airway narrowing, mucus plugging, or air trapping. Tachypnea is often an early compensatory mechanism in asthma; however, sustained or rising respiratory rates despite treatment indicate insufficient response and worsening distress.
Blood pressure 168/90 mm Hg: This is elevated above the client’s baseline and suggests sympathetic nervous system activation due to hypoxia, which triggers vasoconstriction, anxiety and stress, and systemic effects of albuterol, which may cause transient hypertension due to beta-agonist stimulation.
A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?
1000:
Client reports severe abdominal pain. Vital signs obtained. Provider at bedside and labs drawn.
Client appears uncomfortable. Faint yellow hue to sclera. Breath sounds clear bilaterally. 51, 52 auscultated, no murmur. Client is holding abdomen. Abdomen mildly distended. Skin clammy. Reports pain as a 10 on a 0 to 10 numeric pain scale.
1100:
Client is nauseous and is vomiting and states pain is worsening. Rates pain as 8 on a 0 to 10 numeric pain scale. Notified provider, another dose of pain medication administered.
1000:
- Temperature 38.2° C (100.9° F)
- Heart rate 110/min Respiratory rate 22/min
- Blood pressure 98/58 mm Hg
1045:
- WBC 16,500/mm3 (5,000 to 10,00mm3)
- Serum amylase 680 units/L (30 to 220 units/L) Serum lipase 300 units/L (0 to 160 units/L)
1030:
Impression: Pancreatitis
Maintain NPO status
Insert NG tube to low-intermittent suction
A nurse is caring for a client in the emergency department.
Complete the following sentence by using the lists of options.
To implement the provider's prescriptions the nurse should
Explanation
Rationale
Encourage the client to swallow small sips of water and advance tube as patient swallows: Swallowing helps guide the nasogastric tube past the oropharynx and into the esophagus by closing the epiglottis and reducing resistance.
Facilitate the passage of the tube: Coordinating tube advancement with swallowing minimizes discomfort and helps ensure proper placement into the esophagus rather than the airway.
A nurse is providing teaching about measures to promote sleep with a client who has insomnia. Which of the following client statements indicates an understanding of the teaching?
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?
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