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PN ATI Capstone Proctored Post-Assessment
Total Questions : 82
Showing 10 questions, Sign in for moreA nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?
Day 1:
Admitted to medical-surgical unit following open reduction internal fixation of right femur. Alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Bilateral pedal pulses 2+. Movement and sensation of right foot intact, skin warm. Right femur dressing with small serosanguinous drainage.
Day 2:
Client restless and agitated. Respirations rapid. Breath sounds with crackles heard at bases. Client reports substernal chest pain. Dressing to right femur with small serosanguinous drainage. Movement and sensation of right foot intact, skin warm with no change in pigmentation. Bilateral pedal pulses 2+.
Day 1:
- Temperature 37.2° C (98.9° F)
- BP 128/60 mm Hg
- Heart rate 88/min
- Respiratory rate 18/min
- Oxygen saturation 96% on room air
Day 2:
- Temperature 38° C (100.4° F)
- BP 148/60 mm Hg
- Heart rate 112/min
- Respiratory rate 28/min
- Oxygen saturation 88% on room air
A nurse is assisting with the care of a client.
A nurse is reinforcing teaching about HbA1c with a client who has type 1 diabetes mellitus. Which of the following information should the nurse include?
2230:
Client fainted at a fast food restaurant after playing a game of soccer. Client reports drinking the usual sports drinks and salt tablets after the game. Client wasn't feeling hungry but added salt to their lemonade, "since they had sweat so much." Report from emergency medical services included 0.9% sodium chloride 1,000 mL IV bolus given at the scene.
2300:
Sleeping, difficult to awaken. Client states they have never played soccer. Client tries to get out bed, saying they are looking for the cat.
2230:
- Temperature 37° C (98.6° F)
- Heart rate 64/min
- Respiratory rate 18/min
- Blood pressure 124/72 mm Hg
- Hemoglobin 14.5 g/dL (10 to 15.5 g/dL)
- Hematocrit 39% (32% to 44%)
- Sodium 150 mEq/L (136 to 145 mEq/L)
- Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
- Glucose 170 mg/dL (less than 200 mg/dL casual)
- Chloride 105 mEq/L (98 to 106 mEq/L)
- Creatinine 0.6 mg/dL (0.4 to 1.0 mg/dL)
- BUN 14 mg/dL (10 to 20 mg/dL)
- Serum osmolality 300 mOsm/kg H2O (285 to 295 mOsm/kg H2O)
The nurse is assisting in the care of an adolescent athlete in the emergency department.
1000:
32-year-old primigravida client, normal, spontaneous vaginal birth of 3.88 kg (8 lb, 9 oz) newborn at 0945 after a 26-hr labor.
1000:
Alert, oriented x3. Uterine fundus firm, midline, 2 cm below umbilicus. Moderate amount lochia rubra without clots. Bladder nondistended. Perineum intact, no hemorrhoids noted.
1015:
Alert, oriented x3. Uterine fundus boggy, deviated to right of umbilicus. Moderate amount lochia rubra with clots. Uterine fundus becomes firm with massage. Assisted client to void spontaneously.
1030:
Alert, oriented x3. Client states "I am worried, and something doesn't feel right." Client reports gush of fluid between legs. Uterine fundus boggy. Large amount of vaginal bleeding with 3 quarter-size blood clots. Uterine fundus becomes firm with massage.
1045:
Uterine fundus boggy. Perineal pad saturated in 15 min. Uterine tone does not improve with massage. Oxytocin 20 units intramuscularly x1 administered per provider prescription.
1000:
- Temperature 37.5° C (99.5° F)
- Heart rate 78/min
- Respiratory rate 18/min
- Blood pressure 120/80 mm Hg
1015:
- Heart rate 84/min
- Blood pressure 118/78 mm Hg
1030:
- Heart rate 100/min
- Blood pressure 106/72 mm Hg
1045:
- Heart rate 116/min
- Blood pressure 94/64 mm Hg
A nurse is assisting with the care of a client who gave birth.
After review of the medical record of the client, the nurse notes concerning data collection findings.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Potential Condition:
Uterine atony
Boggy uterus, heavy bleeding, fundus responds to massage but returns to boggy state.
Actions to Take:
Massage fundus.
First-line measure to stimulate contraction and reduce bleeding.
Administer IV oxytocin.
Oxytocin promotes uterine contractions to reduce bleeding.
Parameters to Monitor:
Amount of lochia.
Helps assess ongoing blood loss.
Urine output.
Indicates perfusion status and potential hypovolemia.
A nurse is caring for a client who is experiencing a manic episode. The nurse should identify that which of the following factors can prolong the client's mania?
A nurse is caring for a client whose calcium level is 7.6 mg/dL. Which of the following foods should the nurse recommend to the client as containing the greatest amount of calcium?
1 week ago:
Parents report 2-day history of fever, congestion, and cough. Toddler fussy, moderate amount of clear, thick nasal drainage noted. Frequent loose, nonproductive cough. Lungs sound clear. Respirations easy and unlabored.
Today:
Parents report toddler continues with a fever and is now vomiting and difficult to arouse. Parents report administering aspirin and acetaminophen alternately during the past week. Toddler lethargic and frequently vomiting small amounts of clear fluid. Respirations easy and unlabored, nonproductive cough noted. Mucus membranes slightly dry. Parents report no void today.
1 week ago:
- Heart rate 114/min
- Respiratory rate 30/min
- Temperature 38° C (100.4° F)
Today:
- Heart rate 120/min
- Respiratory rate 22/min
- Temperature 39° C (102.2° F)
1 week ago:
- Influenza A NP swab: positive (negative) Influenza B NP swab: negative (negative)
1 week ago:
- Treat with antipyretics. Encourage fluid intake. Return to office if manifestations worsen. Start prescription for oseltamivir for 5 days.
A nurse is assisting in the care of a toddler in the outpatient setting.
Complete the following sentence by using the lists of options.
The nurse recognizes that the toddler has likely developed
Explanation
Correct answer: The nurse recognizes that the toddler has likely developed Reye syndrome due to aspirin administration during a viral illness.
Reye syndrome is a rare but serious condition associated with aspirin use in children recovering from viral infections like influenza. It causes liver dysfunction and cerebral edema, manifesting as vomiting, lethargy, and altered mental status.
A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take to help the client cope with the body image change resulting from the surgery?
A nurse is assisting with the plan of care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse collect?
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