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PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare professional is preparing to administer a dose of naloxone. Which of the following should the healthcare professional assess?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct answer: B
Rationale: Correct. Naloxone is used to reverse opioid overdose, which can cause respiratory depression. Assessing the respiratory rate before administering naloxone is crucial to monitor the patient's breathing. Choices A, C, and D are important assessments in general patient care but are not specifically crucial before administering naloxone for opioid overdose.
2. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?
- A. A client who is able to bear full weight on both lower extremities.
- B. A client who has bilateral leg braces due to paralysis of the lower extremities.
- C. A client who has a right femur fracture with no weight bearing on the affected leg.
- D. A client who has bilateral knee replacements with partial weight bearing on both legs.
Correct answer: C
Rationale: The correct answer is C because a three-point gait is used when the client can bear full weight on one foot and uses crutches and the uninvolved leg to ambulate. Choices A, B, and D are incorrect because they do not meet the criteria for using a three-point gait. Choice A states that the client can bear full weight on both lower extremities, which does not require a three-point gait. Choice B mentions bilateral leg braces due to paralysis, which would not involve using a three-point gait. Choice D describes a client with bilateral knee replacements with partial weight bearing, which also does not align with the use of a three-point gait.
3. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?
- A. Using a night-light
- B. Demonstrating how to use the call light
- C. Placing the bedside table in close proximity
- D. Hourly rounding by the nurse
Correct answer: D
Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.
4. A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?
- A. Dehydration
- B. Urinary incontinence
- C. Poor nutrition
- D. Poor tissue perfusion
Correct answer: B
Rationale: Urinary incontinence is a risk factor for developing pressure injuries due to prolonged skin exposure to moisture and irritants. Dehydration (choice A) can contribute to skin dryness but is not a direct risk factor for pressure injuries. Poor nutrition (choice C) can affect wound healing but is not specifically linked to pressure injuries. Poor tissue perfusion (choice D) can increase the risk of tissue damage but is not as directly associated with pressure injuries as urinary incontinence.
5. A client receiving chemotherapy is experiencing neutropenia. Which of the following should the nurse include in this client's education?
- A. Track oral temperature weekly
- B. Gardening is a good form of mild exercise
- C. Avoid crowded events
- D. Eat plenty of fresh fruits and vegetables
Correct answer: C
Rationale: Clients with neutropenia have a weakened immune system, making them susceptible to infections. Avoiding crowded events helps reduce the risk of exposure to pathogens, thereby minimizing the chance of infections. Tracking oral temperature is important for detecting fever early, which is a sign of infection and requires immediate medical attention. While gardening can be a good form of exercise, clients with neutropenia should avoid it due to the risk of exposure to bacteria and fungi present in soil. Eating fresh fruits and vegetables is generally encouraged for overall health but may carry a risk of bacterial contamination, which could be harmful to a client with neutropenia.
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