ATI Capstone Post Assessments
Questions with Accurate Answers with
Explanation.
A pregnant client has a history of giving birth to one set of twin boys, one term girl and 2 early
spontaneous abortions. What is her gr
...
ATI Capstone Post Assessments
Questions with Accurate Answers with
Explanation.
A pregnant client has a history of giving birth to one set of twin boys, one term girl and 2 early
spontaneous abortions. What is her gravida and para? - Ans-She is gravida 4, Para 2
Gravida indicates the number of times the mother has been pregnant, regardless of whether these
pregnancies were carried to term. A current pregnancy, if any, is included in this count.
Para indicates the number of >20 wks births (including viable and non-viable i.e. stillbirths). Pregnancies
consisting of multiples, such as twins or triplets, count as ONE birth for the purpose of this notation.
A nurse is providing care for an uncircumcised male newborn and his mother. What information should
be provided during discharge regarding bathing of the penile area of the newborn male? - Ans-To
cleanse an uncircumcised penis, wash with soap and water and rinse the penis. The foreskin should not
be forced back or constriction may result.
The 24-year-old client inquires about use of the diaphragm for birth control. What five (5) instructions
would be provided by the nurse to explain use of the diaphragm? - Ans-●A client should be properly
fitted with a diaphragm by a provider.
●Replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery,
and after every pregnancy.
●Requires proper insertion and removal. Prior to coitus, the diaphragm is inserted vaginally over the
cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim.
The diaphragm can be inserted up to 6 hr before intercourse and must stay in place 6 hr after
intercourse but for no more than 24 hr.
●Spermicide must be reapplied with each act of coitus.
●A client should empty her bladder prior to insertion of the diaphragm.
●Diaphragm should be washed with mild soap and warm water after each use.
A nurse is providing teaching about fibrocystic breast tissue with a client. What information will the
nurse share with the client about diagnostics used to confirm the diagnosis? - Ans-Diagnostics for
fibrocystic breast tissue include breast ultrasound and fine-needle aspiration.
A client asks the nurse how often she should get a Papanicolaou (Pap) test. What is the correct response
by the nurse to the client? - Ans-21: All women begin screening for cervical cancer
21-29: Pap test every 3 years; HPV unnecessary unless needed following an abnormalPap test
30-65: Pap and HPV every 5 years
Older than 65: May discontinue testing if regular screenings have been negative; If diagnosed with
cervical precancer, continue to screen
List three (3) actions by the nurse should take during the assessment and data collection steps. - AnsRecognize patterns or trends.
Compare the data with expected standards or reference ranges.
Arrive at conclusions to guide nursing care.
When witnessing an informed consent the nurse must ensure that the provider gives the client the
necessary procedural information. Identify information the provider should disclose to the client to
obtain an informed consent. What is the role of the nurse in this process? - Ans-The Provider obtains the
informed consent. To do so, the provider must give the client:
· The purpose of the procedure· A complete description of the procedure.
· A description of the professional who will perform and participate in the procedure.
· A description of the potential harm, pain or discomfort that might occur.
· Options for other treatments.
· The option to refuse treatment and the consequences of doing so. The nurse must notify the provider
if the client has more questions or appears not to understand any of the information. The provider is
then responsible for giving clarification.
Discuss passive and active immunity. - Ans-Passive: Antibodies are produced by an external source.
Temporary immunity that does not have memory of past exposures. Intact skin, the body's first line of
defense. Mucous membranes, secretions, enzymes, phagocytic cells, and protective proteins.
Inflammatory response with phagocytic cells, the complement system, and interferons to localize the
invasion and prevent its spreadActive: Antibodies are produced in response to an antigen. Requires time
to react to antigens. Provides permanent immunity. Involves B- and T-lymphocytes. Produces specific
antibodies against specific antigens (immunoglobulins [IgA, IgD, IgE, IgG, IgM])
List at least three (3) priority considerations when performing a sterile dressing change. - Ans--Prolonged
exposure to airborne micro-organisms can make sterile items non-sterile.
-Avoid coughing, sneezing, and talking directly over a sterile field.
-Air movement should be controlled by special ventilation.
-Only sterile items may be in a sterile field.
-The outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile.
-The inner surface of the sterile drape or kit, except for that 1-inch border around the edges, is the
sterile field to which additional sterile items may be added.
-To position the field on the table surface, it is acceptable to grasp the 1-inch border before donning
sterile gloves.
-Any object that comes into contact with the 1-inch border must be discarded.
-Touch sterile materials only with sterile gloves.
-Any object held below the waist or above the chest is considered contaminated.
-Sterile materials may touch other sterile surfaces or materials; however, contact with non-sterile
materials at any time renders a sterile area contaminated, no matter how short the contact.
-Microbes can move by gravity from a non-sterile item to a sterile item: Do not reach across or above a
sterile field.
-Do not turn your back on a sterile field.
-Hold items to be added to a sterile field at a minimum of 6 inches above the field.
-Any sterile, non-waterproof wrapper that comes in contact with moisture becomes non-sterile by a
wicking action that allows microbes to travel rapidly from a non-sterile surface to the sterile surface.
-Keep all surfaces dry.
-Discard any sterile packages that become wet.
A nurse is caring for an elderly client with constipation. What are three (3) complications to monitor for
during care of this client? - Ans-Complications of constipation include:Fecal impaction.Development of
hemorrhoids or rectal fissures.Bradycardia, hypotension, and syncope associated with the Valsalva
maneuver (occurs with straining/bearing down).
A nurse is caring for a client who has refused his morning medications. How should the nurse respond to
the client? - Ans-The nurse should recognize the client's right to refuse any medication. The nurse
should explain the consequences of not taking the prescribed medications and encourage the client to
take the medications as prescribed by the provider.
The nurse is caring for a client recently diagnosed with depression. The client was prescribed an SSRI
antidepressant. What assessment findings should be reported to the provider for a client taking this
medication? - Ans-Potential complication/adverse effects to be reported to the provider:
Sexual dysfunction
Insomnia, agitation, anxiety
Changes in weight
Withdrawal syndrome - headache, nausea, visual disturbance, anxiety, dizziness and tremors
Hyponatremia
Rash
Sleepiness, lightheadedness, faintness
Gastrointestinal bleeding
Bruxism
Serotonin syndrome (Can begin 2-72 hours after starting treatment and can be lethal)
Mental confusion, delirium
Fever, tachycardia, elevated blood pressu
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