ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A nurse provides instructions to a client about preventing injury while using crutches. What should the nurse tell the client to avoid?
- A. An abnormal stance
- B. Injury to the nerves
- C. A fall and further injury
- D. Skin breakdown
Correct answer: B
Rationale: The correct answer is B: Injury to the nerves. Resting the underside of the arm on the crutch pad can injure the nerves. Choice A, an abnormal stance, is not directly related to nerve injury while using crutches. Choice C, a fall and further injury, is a general risk associated with improper crutch use but does not specifically address nerve injury. Choice D, skin breakdown, is a concern related to pressure ulcers but not the primary focus when discussing injury prevention related to crutch use.
2. A patient has a DNR (do-not-resuscitate) order but their family insists on resuscitation if necessary. What should the nurse do?
- A. Follow the family's wishes to resuscitate.
- B. Explain that the nurse must follow the DNR order.
- C. Ask the provider for clarification on the DNR.
- D. Call the ethics committee to discuss the situation.
Correct answer: B
Rationale: The correct answer is B. The nurse must follow the legal DNR order, even if the family insists on resuscitation. Respecting the patient's wishes is crucial in providing ethical care. Choice A is incorrect because the nurse should prioritize the patient's documented wishes over the family's requests. Choice C may cause unnecessary delays in care as the DNR order is a legal document. Choice D is not the initial action to take in this situation; the nurse should first address the conflict between the family's wishes and the patient's DNR order.
3. Which nursing action is essential when administering a blood transfusion?
- A. Ensure the blood is administered within 4 hours.
- B. Check the patient's vital signs every 30 minutes during the transfusion.
- C. Administer the transfusion at a slow rate for the first 15 minutes.
- D. Document the transfusion in the patient's medical record immediately after administration.
Correct answer: C
Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.
4. A client expresses concern about hair loss during chemotherapy. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy begins.
- B. Offer resources for wigs and head coverings.
- C. Assure the client that hair loss will be minimal.
- D. Ignore the client's concerns about hair loss.
Correct answer: B
Rationale: During chemotherapy, hair loss is a common side effect. Offering resources for wigs and head coverings can help the client cope with this change in appearance, maintain self-esteem, and feel more comfortable during the process. Encouraging the client to cut their hair short does not address the emotional impact of hair loss and may not be the client's preference. Assuring the client that hair loss will be minimal may provide false hope as significant hair loss is a common occurrence. Ignoring the client's concerns is not appropriate and goes against the principles of providing holistic and compassionate care.
5. A patient with a urinary tract infection (UTI) requires treatment. What is the most appropriate intervention?
- A. Encourage the patient to increase fluid intake.
- B. Administer antibiotics as prescribed.
- C. Recommend the patient take over-the-counter pain relievers.
- D. Encourage the patient to limit physical activity.
Correct answer: B
Rationale: The correct answer is to administer antibiotics as prescribed. Antibiotics are the primary treatment for urinary tract infections as they help eliminate the bacteria causing the infection. Encouraging the patient to increase fluid intake (Choice A) is a supportive measure to help flush out the bacteria but doesn't directly treat the infection. Over-the-counter pain relievers (Choice C) may help with discomfort but do not address the underlying infection. Limiting physical activity (Choice D) may be recommended for some conditions but is not the primary intervention for treating a UTI.
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