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Ati Capstone Proctored Comprehensive
Assessment Form A 43 Quiz 2025
Questions And Answers.
100% A+
Electrolyte Imbalances: Identifying Manifestations of a Calcium Imbalance
Hypocalcemia:
- Level: <9 mg/dL
- Risk factors: Calcium deficit, diarrhea, end-stage kidney disease, wound drainage; alkalosis, acute pancreatitis, immobility, parathyroid removal/damage
- S&S: Tetany (most common manifestation), paresthesia of the fingers and lips, muscle twitches,
seizure, muscle spasms, hyperactive DTRs, positive Chvostek's sign (facial twitching), positive Trousseau's sign (hand/finger spasms with BP cuff inflation), cardiovascular irregularities, diarrhea, abdominal cramps
- Tx: Vitamin D supplements
- Complications: Cardiac arrest
Associated manifestation of Hypocalcemia
Positive Trousseau's sign
Associated manifestation of Hyperkalemia
ECG with tall, peaked t-waves
Associated manifestation of Hyponatremia
Bounding pulse
Associated manifestation of Hypokalemia
Hypoactive bowel sounds
The nurse is assessing the client for Chvostek's sign. Which of the following actions should the nurse take?
a. Apply a BP cuff to the client's arm
b. Place a stethoscope bell over the client's carotid artery
c. Ask the client to lower their chin to their chest
d. Tap lightly on the client's cheek
d. Tap lightly on the client's cheek
Tap over the facial nerve just below and anterior to the ear to elicit Chvostek's sign.
A positive sign = Facial twitching on the side of the face
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which of the following findings are manifestations of hypocalcemia? SATA
a. Tingling in fingers
b. Poor skin turgor
- Encourage deep breathe to assist with lung expansion
- Obtain a postprocedure cxr
Thoracentesis
Thoracentesis is the surgical perforation of the chest wall and pleural space with a large-bore needle. It is performed to obtain specimens for diagnostic evaluation, instill medication into the pleural space, and remove fluid or air from the pleural space for therapeutic relief of pleural pressure.
A nurse is reviewing information with a client who is scheduled for pulmonary function tests. Which of the following statements should the nurse make?
a. "Do not use inhaler medications for 6 hr following the test."
b. "Do not smoke tobacco for 6-8 hr prior to the test."
c. "You will be asked to bear down and hold your breath during the test."
d. "The arterial blood flow to your hand will be evaluated as part of the test."
b. "Do not smoke tobacco for 6-8 hr prior to the test."
To ensure accurate results
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the clients room? SATA
a. Oxygen equipment
b. Incentive spirometer
c. Pulse oximeter
d. Sterile dressing
e. Suture removal kit
a, c, d
a. Oxygen equipment for SOB
b. Pulse ox to monitor ox sat during procedure
d. Sterile dressing to apply to the puncture site
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?
a. Position the client upright, leaning over the bedside table
b. Explain the procedure to the client
c. Perform an Allen's test on the client
d. Administer benzocaine spray to the client
a. Position the client upright, leaning over the bedside table
It widens the intercostal space for the provider to access the pleural fluid
A nurse is assessing a client following a thoracentesis. Which of the following findings should the nurse report? SATA
a. dyspnea
b. localized bloody drainage on the dressing
c. fever
d. hypotension
e. report of pain at the puncture site
Chest Tube Systems
A disposable three - chamber drainage system is most often used
- First chamber: drainage collection
- Second chamber: Water seal
- Third chamber: Suction control (can be wet or dry)
Continuous bubbling in the water seal chamber indicates...
Air leak in the system.
When the tubes are inserted to remove air from the pleural space, intermittent bubbling is...
expected.
It is common to see bubbling during...
- exhalation
- sneezing
- coughing
A nurse is preparing to care for a client who is having a chest tube placed. Which of the following items should be available in the clients room? SATA
a. Oxygen
b. Sterile water
c. enclosed hemostat clamps
d. Indwelling urinary catheter
e. occlusive dressing
a, b, c, e
Oxygen = respiratory distress following chest tube placement
Sterile water = If tubing becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal
Hemostat clamps = To check for air leaks. If tubing becomes disconnected, place a gauze dressing over the site
Occlusive dressing = Prevents redevelopment of a pneumothorax
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following actions should be included in the place of care? SATA
a. Encourage the client to cough and deep breathe
b. Check for continuous bubbling in the suction chamber
c. Strip the chest tube drainage tubing every 4 hr
d. Clamp the chest tube once a day
e. Obtain a chest x-ray
a, b, e
Cough and deep breathe = promotes oxygenation and lung re-expansion
Continuous bubbling in the suction chamber = suction is maintained
CXR = Chest tube placement
c. Remind the client that there is minimal discomfort during the removal process
d. Place an occlusive dressing over the site once the tube is removed
d. Place an occlusive dressing over the site once the tube is removed
Observe the site for drainage.
Modified Diets: Selecting Foods for a Client Who Has Dysphagia
Mechanical soft diet:
- Foods that require minimal chewing before swallowing
- Ground meats, canned fruit, softly cooked vegetables
Dysphagia diet:
- Levels of liquid consistencies
- Levels of solid textures
Levels of liquid consistencies
- Level 0: Thin; liquid that flows like water, can be consumed through cup or a straw
- Level 1: Slightly thick; thin enough to sip through a straw but thicker than water
- Level 2: Mildly thick; Liquids that do not maintain their shape when poured but are thickened. Can be eaten with a spoon and requires effort to be sipped through a straw.
- Level 3: Moderately thick; Liquids with smooth texture and no lumps, can be consumed from a cup or spoon but not a fork
- Level 4: Extremely thick; Liquids thickened to maintain their shape and need to be eaten with a spoon, not sticky, does not require chewing
Levels of solid textures
- Level 3: Liquidized; Level 3 Liquid Consistency
- Level 4: Pureed; Level 4 Liquid Consistency
- Level 5: Minced and Moist; Soft, visible lumps, can be consumed with fork or spoon if lumps are easy to mash with tongue
- Level 6: Soft and bite-sized; Soft-textured, moist, semi-solid foods that are easily chewed and swallowed
- Level 7: Regular; Normal everyday food, vary in texture
Manifestations of dysphagia
- Drooling
- Pocketing food
- Chocking or gaggin
Dysphagia diet
Prescribed when swallowing is impaired.
A nurse is assisting a client who has a prescription for a mechanical soft diet with food selections. Which of the following are correct selections by the client? SATA
a. Dried prunes
b. ground turkey
c. mashed carrots
d. fresh strawberries
Anticholinergic
MOA: Interferes with the transmission of nerve impulses traveling from the vestibular apparatus of the inner ear to the vomiting center in the brain.
Indication:
- Prevention and treatment of motion sickness
Side effects:
- Dry mouth, urinary retention, constipation
NC:
- Administer laxative or stool softener to prevent constipation
Contraindications:
DM: Mixing Insulins in the Same Syringe
When mixing short-acting insulin with longer-acting insulin:
- Draw the short-acting insulin up into the syringe first
- Draw the longer-acting insulin next
Rapid-acting Insulins
Peak: 0.5-3 hours
- Lispro
- Aspart
- Glulisine
- Human insulin
Short-acting Insulins
Peak: 1-5 hours
- Regular insulin (U-500, U-100)
Intermediate-acting Insulin
Peak: 4-14 hours
NPH insulin
Long-acting Insulin
Peak: None
Antibiotics Affecting Protein Synthesis: Providing Client Education About Tetracycline
- Take with meals if GI distress occurs
- Take on empty stomach with 8 oz of water
- Avoid taking at bedtime
- Do not take it before lying down
- Complete entire course
- Utilize additional contraceptives
- Wear protective clothing and use sunscreen with an SPF of 30 or higher while outdoors
- Superinfection
- Pregnancy and lactation , oral contraceptives
- Use cautiously with liver and kidney disease
Interactions:
- Milk
- Calcium and iron supplements
- Laxatives with magnesium
A nurse is providing teaching with a client who has a new prescription for tetracycline to treat a GI infection due to H. pylori. Which of the following client statements indicate understanding?
a. "I will take this medication with 8 oz of milk."
b. "I will report if I start having diarrhea while taking this medication."
c. "I can stop taking this medication when I feel completely well."
d. "I can take this medication just before bedtime."
b. "I will report if I start having diarrhea while taking this medication."
Diarrhea = Indication of developing a superinfection
Medical Conditions: Prioritizing Antepartum Client Care
Infection Control: Infectious Diseases to Report
60 communicable diseases that must be reported to the public health departments
- TB
