ATI Comprehensive Test B / RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. A nurse is caring for a client who had abdominal surgery 24 hours ago. Which of the following actions is the priority? A. Assess fluid intake every 24 hours B. Ambulate three times a day C. Assist with deep breathing and coughing D. Monitor the incision site for findings of infection - C The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia. 2. A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism? A. I have experienced physical discomfort when intimate with my partner since my diagnosis B. I wish other women would stop socializing with my partner C. I told my doctor that I would like to start a support group for other women who are sick in my community D. I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness - C This statement indicates that the client is using the constructive defense mechanism sublimation by devising a socially acceptable alternative to facing a reality that she does not wish to accept. 3. A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A. Assess the clients IV site every 8 hours B. Check the clients WBC count every 48 hours C. Monitor the clients mouth every 8 hours D. Change the clients IV tubing every 48 hours - C 4. A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? A. Eyes area B. Chest area C. Lower abdominal area - C Hirschsprung disease is a condition that affects the large intestine (colon) and causes problems with passing stool. This is present at birth (congenital) as a result of missing nerve cells in the muscle of the baby's colon 5. A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A. A client forgets to buy their partner a birthday gift after a disagreement B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter than average is verbally assertive with coworkers D. A client states that they did not get a job promotion because the boss did not like them - B 6. A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? A. irritability B. increased urination C. vomiting D. facial flushing - A 7. A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? A. A client who transfers their anger about their job onto their family and then apologizes B. A client who misses provider appointments because they say they are too busy C. A client who channels their energy into a new hobby following the loss of their job D. A client whose partner died 4 years ago sets a place for him at dinner each night - C The nurse should identify that this client is using the defense mechanism of sublimation by channeling negative feelings over the loss of their job into a new hobby. 8. A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? A. "We can expect the hospice nurse to provide support for us after our mother's death." B. A hospice nurse will come to the house each time our mother needs pain medication C. Now that my mother is receiving hospice services, we will not be able to get respite care D. Hospice care focuses on arranging treatment that will prolong our mother's life - A Hospice care includes bereavement services after a family member's death. 9. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? A. Wear a surgical mask when providing client care B. Have visitors maintain a distance of 1.8m (6 feet) from the client C. Restrict fresh flowers from the clients room D. Assign the client to a private room with negative air pressure - D 10. A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? A. Limit your fat intake for 72 hours before the test B. You will need to fast the night before the test C. We will collect a urine sample the day after testing D. A blood sample will be collected every 15 minutes during the test - B