ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Inject at a 90-degree angle
- B. Inject at a 45-degree angle
- C. Massage the injection site after administering
- D. Use a longer needle
Correct answer: B
Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.
2. A client has a new prescription for clopidogrel. Which of the following instructions should the nurse include?
- A. Take this medication with food
- B. Take this medication three times daily
- C. You might have to stop taking this medication 5 days before any planned surgeries
- D. Expect to have black-colored stools while taking this medication
Correct answer: C
Rationale: The correct answer is C. When instructing a client who is prescribed clopidogrel, the nurse should include information about stopping the medication 5 days before any planned surgeries to reduce the risk of bleeding. This is crucial to prevent excessive bleeding during surgical procedures. Choices A, B, and D are incorrect because taking the medication with food, the frequency of administration, and the possibility of black-colored stools are not specific instructions related to clopidogrel use.
3. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?
- A. Positioning the patient in a prone position
- B. Monitoring vital signs and lung sounds
- C. Preparing for mechanical ventilation
- D. Administering supplemental oxygen
Correct answer: A
Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.
4. What are the key components of a pain assessment in a postoperative patient?
- A. Checking the effectiveness of pain interventions
- B. Observing for nonverbal signs of pain like grimacing
- C. Assessing the location, duration, and quality of the pain
- D. Asking the patient to rate their pain on a scale of 1-10
Correct answer: A
Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.
5. A client has bilateral eye patches following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
- A. Explain to the client that their tray is here and place their hands on it
- B. Ask the client if they would prefer a liquid diet
- C. Assign an assistive personnel to feed the client
- D. Describe to the client the location of the food on the tray
Correct answer: D
Rationale: Describing the location of food on the tray helps promote independence for the client with bilateral eye patches. By providing clear instructions on where the food is placed, the client can independently locate and consume their meal. Option A is incorrect as physically placing the client's hands on the tray does not encourage independence. Option B is unnecessary unless there are specific dietary restrictions indicated. Option C does not promote the client's independence and should be avoided unless absolutely necessary.
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