ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A community health nurse is providing an educational session on childhood poisoning at a local school. What should the nurse advise as the first action if poisoning occurs?
- A. Call the poison control center
- B. Bring the child to the emergency department (ED)
- C. Induce vomiting
- D. Call an ambulance
Correct answer: A
Rationale: In the event of poisoning, the recommended first action is to call the poison control center. Poison control specialists can provide immediate guidance on how to manage the situation effectively. Bringing the child to the emergency department (Choice B) may be necessary depending on the severity of the poisoning, but contacting poison control first is crucial for appropriate and timely intervention. Inducing vomiting (Choice C) is not advised in all cases of poisoning and should only be done under the guidance of healthcare professionals. Calling an ambulance (Choice D) may be necessary in some severe cases, but the initial step should be to contact poison control for expert advice.
2. A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client. What is the nurse's responsibility?
- A. Contact the stoma nurse immediately.
- B. Educate the client on stoma care.
- C. Assess the stoma site for complications.
- D. Arrange for follow-up visits with the stoma nurse.
Correct answer: B
Rationale: The correct answer is B: 'Educate the client on stoma care.' The nurse's primary responsibility in this scenario is to provide education to the client on stoma care. This empowers the client to take care of their colostomy effectively. While it is important to involve the stoma nurse for specialized care, the immediate action required from the nurse is client education. Choice A is incorrect as the immediate action is not to contact the stoma nurse but to educate the client first. Choice C is not the nurse's initial responsibility unless there are obvious complications. Choice D is premature as arranging follow-up visits should come after the client has been educated and initial care has been provided.
3. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?
- A. Immediately do a complete head-to-toe neurological assessment.
- B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
- C. Place a blanket over the feet.
- D. Remove the restraint.
Correct answer: D
Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.
4. A nurse is preparing medications for a client via nasogastric tube. What should the nurse do before administering the medications?
- A. Flush the tube with water and administer all medications at once
- B. Administer medications one after the other without flushing
- C. Crush all medications and mix them together for administration
- D. Administer medications in liquid form only
Correct answer: B
Rationale: Before administering medications through a nasogastric tube, the nurse should administer them one after the other without flushing. Flushing the tube with water should be done before and after each medication to prevent any interactions and ensure each medication is delivered effectively. The correct answer is not to administer all medications at once (choice A) as this can lead to potential drug interactions. Crushing all medications and mixing them together (choice C) is incorrect as each medication should be given separately to maintain their individual efficacy. Administering medications in liquid form only (choice D) is limiting and may not be suitable for all types of medications that need to be administered.
5. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?
- A. Suction the tracheostomy to maintain a patent airway.
- B. Administer pain medication as prescribed.
- C. Change the tracheostomy dressing every 4 hours.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.
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