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. A nurse is preparing to administer medication to a client by nasogastric tube. What should the nurse do first?
- A. Administer the medication without further assessment.
- B. Check the tube placement before administering any medication.
- C. Administer the medication in liquid form only.
- D. Administer half the dosage as a precaution.
Correct answer: B
Rationale: The correct answer is B: Check the tube placement before administering any medication. Before administering medication through a nasogastric tube, the nurse must first verify the tube's correct placement to ensure the medication reaches the stomach and to prevent complications such as aspiration. Options A, C, and D are incorrect because administering medication without confirming proper tube placement can lead to serious consequences for the client.
3. What is the most appropriate action for a healthcare professional to take when a medication error occurs?
- A. Document the error in the patient's medical record.
- B. Report the error to the healthcare provider immediately.
- C. Apologize to the patient and explain what happened.
- D. Continue administering the medication and monitor the patient closely.
Correct answer: B
Rationale: When a medication error occurs, the most appropriate action for a healthcare professional is to report the error to the healthcare provider immediately. This is crucial for ensuring prompt corrective action to mitigate any potential harm to the patient. Documenting the error is important but should come after reporting it to the relevant authorities. Apologizing to the patient is important for maintaining trust and communication but should not take precedence over reporting and addressing the error. Continuing to administer the medication without addressing the error is unsafe and goes against patient safety protocols.
4. Which intervention is most effective in preventing postoperative complications?
- A. Encourage the patient to drink fluids.
- B. Ambulate the patient as soon as possible.
- C. Perform deep breathing exercises with the patient.
- D. Encourage the patient to perform range of motion exercises.
Correct answer: B
Rationale: The most effective intervention in preventing postoperative complications is to ambulate the patient as soon as possible. Early ambulation helps prevent complications like deep vein thrombosis and pneumonia by enhancing circulation and preventing respiratory issues. Encouraging the patient to drink fluids, perform deep breathing exercises, or range of motion exercises are beneficial interventions, but ambulation is the priority due to its overall impact on preventing various postoperative complications.
5. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?
- A. Wear gloves when entering the patient's room.
- B. Place the patient in a private room.
- C. Use a dedicated blood pressure cuff for the patient.
- D. Dispose of all equipment in a biohazard bag.
Correct answer: A
Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.
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