Question

A nurse is caring for a client who is on long-term therapy for peptic ulcer disease and has a new diagnosis of osteoporosis. The nurse should identify that osteoporosis is an adverse effect of which the following medications?

Answer 1

Correct Answers:

Omeprazole

Rationale :

🔹 Omeprazole is a proton pump inhibitor (PPI) used long-term for peptic ulcer disease

🔹 Chronic PPI use reduces calcium absorption by decreasing gastric acid

🔹 Reduced calcium absorption leads to decreased bone mineral density

🔹 Long-term therapy is associated with an increased risk of osteoporosis and fractures

🔹 This adverse effect is most significant with prolonged use

Famotidine

🔹 Famotidine is an H2 receptor antagonist

🔹 It has a much lower risk of bone density loss compared to PPIs

Bismuth

🔹 Bismuth is used for H. pylori treatment and gastric protection

🔹 It is not associated with bone metabolism changes

Magnesium hydroxide

🔹 Magnesium hydroxide is an antacid/laxative

🔹 It does not cause osteoporosis and may actually supply magnesium

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Answer 2

Correct Answers:

Suctioning device

Rationale :

🔹 A suctioning device is necessary to maintain a patent airway during or after a seizure

🔹 Seizure activity can cause excess secretions or emesis, increasing aspiration risk

🔹 Immediate suction access supports airway clearance and oxygenation

🔹 Seizure precautions prioritize airway and safety, not restraint or oral devices

🔹 This equipment should be available in the room for rapid use

Vest restraint

🔹 Restraints are contraindicated during seizures

🔹 They increase the risk of injury

Bite block

🔹 Bite blocks should not be inserted during seizures

🔹 They can cause jaw, dental, or airway injury

Padded tongue blade

🔹 Tongue blades are never used for seizures

🔹 They pose a high risk of oral trauma and obstruction

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Answer 3

Correct Answers:

Frequent swallowing

Rationale :

🔹 Frequent swallowing is a classic sign of postoperative hemorrhage after a tonsillectomy

🔹 Children may swallow repeatedly to clear blood trickling down the throat

🔹 Post-tonsillectomy bleeding is a medical emergency that can quickly lead to airway compromise

🔹 Early recognition is critical to prevent significant blood loss and aspiration

🔹 This finding requires immediate nursing action and provider notification

Blood-tinged mucus

🔹 Small amounts of blood-tinged saliva are expected after surgery

🔹 This does not indicate active bleeding

Sore throat

🔹 Throat pain is a normal postoperative finding

🔹 It is managed with prescribed analgesics

Dark brown emesis

🔹 This often represents old blood swallowed during surgery

🔹 While monitored, it is less urgent than signs of active bleeding

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Answer 4

Correct Answers:

Inject the needle at a 45° to 90° angle

Rationale :

🔹 Subcutaneous injections are administered at a 45° to 90° angle, depending on the amount of subcutaneous tissue

🔹 Morphine given subcutaneously must be placed into fatty tissue, not muscle

🔹 Using the correct angle ensures proper absorption and reduces tissue injury

🔹 This technique is standard for subcutaneous medication administration

🔹 It supports safe and effective pain management

Displace the skin 2.5 cm (1 in) to the side

🔹 This describes the Z-track technique, which is used for intramuscular injections, not subcutaneous

Pull the plunger back for 5 seconds

🔹 Aspiration is not recommended for subcutaneous injections

🔹 It increases discomfort without improving safety

Use a 23-gauge needle

🔹 Subcutaneous injections typically use a 25–27 gauge needle

🔹 A 23-gauge needle is more appropriate for intramuscular injections

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Answer 5

Correct Answers:

Administer azithromycin

Rationale :

🔹 Azithromycin is a macrolide antibiotic and is the treatment of choice for pertussis

🔹 Early antibiotic therapy helps reduce transmission and may shorten the course if given promptly

🔹 Infants are at high risk for severe complications, so timely treatment is critical

🔹 Macrolides are preferred because they are effective against Bordetella pertussis

🔹 This intervention directly addresses the cause of the infection

Administer oseltamivir

🔹 Oseltamivir is used to treat influenza, not pertussis

🔹 It has no effect on bacterial infections

Initiate contact precautions

🔹 Pertussis requires droplet precautions, not contact precautions alone

🔹 While isolation is important, this option is incomplete

Obtain a stool culture

🔹 Stool cultures are used for gastrointestinal infections

🔹 Pertussis is a respiratory illness, not diagnosed via stool

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Answer 6

Correct Answers:

Excessive sweating

Rationale :

🔹 Excessive sweating (diaphoresis) is a key early sign of serotonin syndrome, a potentially life-threatening condition

🔹 Serotonin syndrome results from excess serotonergic activity, often after starting or increasing an SSRI like sertraline

🔹 Autonomic instability is characteristic and includes diaphoresis, fever, tachycardia, and hypertension

🔹 Early recognition and reporting are critical to prevent progression to severe complications

🔹 This symptom requires immediate medical evaluation

Insomnia

🔹 Insomnia is a common side effect of SSRIs

🔹 It does not indicate serotonin toxicity

Constipation

🔹 Constipation can occur with antidepressants

🔹 It is not associated with serotonin syndrome

Dry mouth

🔹 Dry mouth is a frequent, non-emergent side effect

🔹 It does not suggest serotonergic excess

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Answer 7

Correct Answers:

When the client has communicated an intention to harm someone

Rationale :

🔹 Nurses have a legal and ethical duty to protect when a client expresses intent to harm others

🔹 This situation falls under the duty to warn and protect, which overrides confidentiality

🔹 Reporting is required to prevent imminent danger to the client or others

🔹 Health care providers must notify appropriate authorities or the healthcare team

🔹 This exception to confidentiality is clearly defined in law and professional standards

When the client's hospitalization is involuntary

🔹 Involuntary admission does not remove confidentiality rights

🔹 Client information is still protected

When a member of the client's immediate family requests information

🔹 Family members are not automatically entitled to confidential information

🔹 Disclosure requires client consent unless legally authorized

When the client has a cognitive disorder

🔹 A cognitive disorder alone does not justify breaking confidentiality

🔹 Information is shared only with authorized caregivers when appropriate

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Answer 8

Correct Answers:

Numbness in the toes

Rationale :

🔹 Numbness in the toes is a critical sign of neurovascular compromise following cast application

🔹 This finding may indicate impaired circulation or nerve compression caused by a tight cast

🔹 Untreated neurovascular impairment can progress to ischemia, permanent nerve damage, or compartment syndrome

🔹 Early detection allows for immediate intervention, such as cast loosening or removal

🔹 This is a priority (ABCs/circulation) assessment finding requiring prompt action

Ecchymosis at the base of the toes

🔹 Bruising is an expected finding after a fracture

🔹 It does not indicate acute compromise

Pain at the fracture site with movement

🔹 Pain with movement is anticipated after fracture stabilization

🔹 It is managed with immobilization and analgesia

Mild edema to the toes

🔹 Mild swelling is common after casting

🔹 It is expected and monitored, not emergent

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Answer 9

Correct Answers:

"Can you tell me how you are feeling?"

Rationale :

🔹 This statement is open-ended and nonjudgmental, encouraging the child to express feelings safely

🔹 It helps establish trust and therapeutic communication, which is essential after abuse

🔹 The nurse avoids leading, blaming, or pressuring the child

🔹 Emotional assessment is a priority in suspected abuse cases

🔹 This approach supports accurate, unbiased information gathering

“Explain what you were doing to get hit.”

🔹 This implies blame toward the child

🔹 It is inappropriate and can shut down communication

“Why do you think that you are being abused?”

🔹 “Why” questions can feel accusatory

🔹 The child may not understand or feel responsible

“I am sure everything will work out just fine.”

🔹 This gives false reassurance

🔹 It minimizes the seriousness of the situation

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Answer 10

Correct Answers:

10

Rationale :

🔹 Step 1: Identify the concentration of heparin

🔹 25,000 units in 250 mL

🔹 Step 2: Calculate units per mL

🔹 25,000 ÷ 250 = 100 units/mL

🔹 Step 3: Identify the prescribed dose

🔹 Ordered dose = 1,000 units/hr

🔹 Step 4: Calculate mL per hour

🔹 mL/hr = 1,000 units/hr ÷ 100 units/mL

🔹 Step 5: Compute

🔹 mL/hr = 10

🔹 Step 6: Set the IV pump

10 mL/hr

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RN ATI Capstone Proctored Pre-Assessment

No.

1 :
A nurse is caring for a client who is on long-term therapy for peptic ulcer disease and has a new diagnosis of osteoporosis. The nurse should identify that osteoporosis is an adverse effect of which the following medications?

2 :
A nurse is implementing seizure precautions for a newly admitted client. Which of the following equipment should the nurse place in the client's room?

3 :
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

4 :
A nurse is planning to administer morphine 5 mg subcutaneously to a client for pain management. Which of the following actions should the nurse plan to take?

5 :
A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take?

6 :
A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

7 :
A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?

8 :
A nurse is assessing a client who has just had a lower-leg cast application to stabilize an ankle fracture. Which of the following findings in the affected extremity is the nurse's priority?

9 :
A nurse in the emergency department is caring for a school-age child following an incidence of physical abuse. Which of the following statements should the nurse make?

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RN ATI Capstone Proctored Pre-Assessment

No.

1 : A nurse is caring for a client who is on long-term therapy for peptic ulcer disease and has a new diagnosis of osteoporosis. The nurse should identify that osteoporosis is an adverse effect of which the following medications?

2 : A nurse is implementing seizure precautions for a newly admitted client. Which of the following equipment should the nurse place in the client's room?

3 : A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

4 : A nurse is planning to administer morphine 5 mg subcutaneously to a client for pain management. Which of the following actions should the nurse plan to take?

5 : A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take?

6 : A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

7 : A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?

8 : A nurse is assessing a client who has just had a lower-leg cast application to stabilize an ankle fracture. Which of the following findings in the affected extremity is the nurse's priority?

9 : A nurse in the emergency department is caring for a school-age child following an incidence of physical abuse. Which of the following statements should the nurse make?

1 :
A nurse is caring for a client who is on long-term therapy for peptic ulcer disease and has a new diagnosis of osteoporosis. The nurse should identify that osteoporosis is an adverse effect of which the following medications?

2 :
A nurse is implementing seizure precautions for a newly admitted client. Which of the following equipment should the nurse place in the client's room?

3 :
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

4 :
A nurse is planning to administer morphine 5 mg subcutaneously to a client for pain management. Which of the following actions should the nurse plan to take?

5 :
A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take?

6 :
A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

7 :
A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?

8 :
A nurse is assessing a client who has just had a lower-leg cast application to stabilize an ankle fracture. Which of the following findings in the affected extremity is the nurse's priority?

9 :
A nurse in the emergency department is caring for a school-age child following an incidence of physical abuse. Which of the following statements should the nurse make?