ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. When the nurse discovers a patient on the floor, and the patient states, 'I fell out of bed,' the nurse assesses the patient and then places the patient back in bed. What action should the nurse take next?
- A. Re-assess the patient.
- B. Complete an incident report.
- C. Notify the healthcare provider.
- D. Do nothing, as no harm has occurred.
Correct answer: C
Rationale: After a patient has fallen, it is crucial to notify the healthcare provider. The provider needs to be informed so that further assessment, evaluation, or intervention can be carried out to ensure the patient's safety and well-being. Re-assessing the patient (Choice A) is important but notifying the healthcare provider takes precedence. Completing an incident report (Choice B) is necessary but should follow notifying the healthcare provider. Doing nothing (Choice D) is not appropriate as patient safety and potential underlying issues need to be addressed promptly.
2. How should a nurse respond to a client with terminal cancer who has requested a change in the level of pain medication?
- A. Increase the dosage without consulting the healthcare provider.
- B. Consult with the healthcare provider to adjust the medication.
- C. Ignore the request as the client is near the end of life.
- D. Increase the medication to reduce pain faster.
Correct answer: B
Rationale: The correct answer is to consult with the healthcare provider to adjust the medication. It is crucial for the healthcare provider to be involved in changing pain medication for a client with terminal cancer to ensure that the new dosage is appropriate and safe. Option A is incorrect because adjusting medication without consulting the healthcare provider can be dangerous and is not within the scope of the nurse's practice. Option C is incorrect because ignoring the client's request goes against the principles of patient-centered care. Option D is incorrect as the primary goal should be to provide effective pain relief with the appropriate dosage, not to increase the medication arbitrarily.
3. Which factor places a patient at the highest risk for infection?
- A. A healthy immune system
- B. Presence of chronic illness
- C. Being well-nourished
- D. Age over 65 years
Correct answer: B
Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.
4. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy.
- B. Provide resources for wigs or hairpieces.
- C. Assure the client that hair loss will be minimal.
- D. Offer the client medication to reduce the chances of hair loss.
Correct answer: B
Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.
5. A nurse sees another nurse administering medication without using alcohol swabs. What is the first action the nurse should take?
- A. Ignore the situation to maintain a good working relationship.
- B. Report the behavior to the nurse manager.
- C. Ask the colleague to be more careful next time.
- D. Report the issue after speaking to other colleagues.
Correct answer: B
Rationale: The correct action for the nurse to take when witnessing unsafe medication administration practices, such as not using alcohol swabs, is to report the behavior to the nurse manager immediately. Patient safety is the top priority, and any actions that compromise it must be addressed promptly. Ignoring the situation (Choice A) is not appropriate as it puts patients at risk. Asking the colleague to be more careful (Choice C) may not be effective in ensuring immediate correction of the unsafe practice. Reporting the issue after speaking to other colleagues (Choice D) delays necessary action and may compromise patient safety further.
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