ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. The family member is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings?
- A. The family member saves part of the dressing because it is clean.
- B. The family member places the used dressings in a plastic bag.
- C. The family member removes gloves and gathers items for disposal.
- D. The family member wraps the used dressing in toilet tissue before placing it in the trash.
Correct answer: B
Rationale: The correct way to manage contaminated dressings is to place them in plastic bags for proper disposal. This helps prevent the spread of infection. Choice A is incorrect because saving part of the dressing is not a recommended practice. Choice C is not directly related to managing contaminated dressings. Choice D is incorrect as wrapping the used dressing in toilet tissue is not the appropriate way to dispose of contaminated dressings.
2. A client is undergoing chemotherapy and expresses concern about hair loss. What is the best response?
- A. Reassure the client that hair loss is not permanent.
- B. Provide resources for wigs or hairpieces.
- C. Encourage the client to cut their hair short in advance.
- D. Advise the client that chemotherapy causes temporary hair loss.
Correct answer: D
Rationale: The best response when a client undergoing chemotherapy expresses concern about hair loss is to advise them that chemotherapy causes temporary hair loss. This response provides accurate information to the client about the side effect they are experiencing. Choice A is incorrect because it may provide false reassurance as for some individuals, hair loss can be a challenging experience. Choice B is not the best initial response as addressing the client's concerns and providing information should come first. Choice C is not the most appropriate response as cutting hair short may not necessarily prevent hair loss and does not address the client's concerns about the temporary nature of chemotherapy-induced hair loss.
3. A client undergoing surgery refuses to remove religious jewelry. What is the best course of action?
- A. Proceed with surgery while securing the jewelry to the patient.
- B. Remove the jewelry and document the removal.
- C. Document the refusal and delay the surgery.
- D. Remove the jewelry with the family's permission.
Correct answer: B
Rationale: The correct course of action is to remove the jewelry and document the removal. While religious beliefs should be respected, ensuring patient safety during surgery is crucial. Securing the jewelry may not be sufficient to prevent any interference during the surgical procedure. Documenting the removal is important for legal and documentation purposes. Delaying the surgery or removing the jewelry with the family's permission may not be the best options as patient safety should be the top priority in this situation.
4. A healthcare provider orders a medication dose three times higher than usual. What is the nurse's first step?
- A. Administer the medication but monitor the patient closely.
- B. Verify the dosage with the prescribing provider.
- C. Administer a lower dose to minimize the risk.
- D. Hold the medication and wait for further clarification.
Correct answer: B
Rationale: The correct answer is B: Verify the dosage with the prescribing provider. When faced with an unusual medication dose, the nurse's initial action should be to confirm the order with the healthcare provider who prescribed it. This step is crucial to prevent medication errors and ensure patient safety. Choices A, C, and D are incorrect because administering the medication without clarification, administering a lower dose without approval, or holding the medication without consulting the provider can all pose risks to the patient's well-being.
5. A client complains of pain in their leg, and the nurse notes swelling and pallor. What is the priority nursing action?
- A. Administer pain medication.
- B. Elevate the limb and monitor closely.
- C. Encourage movement to reduce swelling.
- D. Notify the provider immediately about the symptoms.
Correct answer: D
Rationale: The correct answer is D: Notify the provider immediately about the symptoms. Swelling and pallor in a limb can be indicative of serious circulatory issues or compartment syndrome. It is crucial to inform the healthcare provider promptly to assess and address the situation. Administering pain medication (choice A) may temporarily alleviate the symptoms but does not address the underlying cause. Elevating the limb and monitoring closely (choice B) can be beneficial but does not replace the need for immediate professional evaluation. Encouraging movement to reduce swelling (choice C) is contraindicated in this scenario as it may worsen the condition if a circulatory issue or compartment syndrome is present.
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