PN ATI Capstone Proctored Comprehensive Assessment Form A

Correct Answer: A

Rationale: Using a designated stethoscope for the toddler is crucial to reduce the risk of spreading RSV to other patients. Choice B is incorrect because N95 respirator masks are not specifically indicated for RSV. Choice C is unnecessary as RSV does not require isolation in a negative pressure room. Choice D is incorrect because the gown should be removed after leaving the room to prevent transmission of pathogens to other areas.

Correct Answer: B

Rationale: The correct answer is B. A PaCO2 level of 55 mm Hg is elevated, indicating carbon dioxide retention, a common complication of emphysema that necessitates intervention. Elevated PaCO2 can lead to respiratory acidosis, reflecting inadequate ventilation. Choices A, C, and D are within normal ranges. A PaO2 level of 89 mm Hg is acceptable. An HCO3 level of 25 mEq/L falls within the normal range, suggesting adequate compensation. A pH level of 7.37 is also within the normal range, indicating the client's acid-base balance is maintained.

Correct Answer: B

Rationale: A flat anterior fontanel indicates improved hydration in infants, as dehydration typically causes sunken fontanels.

Correct Answer: D

Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.

Correct Answer: C

Rationale: The correct answer is C because the client should press the PCA pump button when they start to feel pain. This approach helps maintain pain control effectively. Choice A is incorrect because waiting for the pain to become severe before using the PCA pump can lead to inadequate pain management. Choice B is incorrect because only the client should operate the PCA pump to ensure the correct dosage is administered. Choice D is incorrect because the client should press the button as needed when experiencing pain, rather than limiting its use to once per hour.