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 observing a patient's use of a walker. Which observation indicates a need for further teaching?
- A. The patient advances the walker too far ahead.
- B. The patient uses the walker to assist in standing.
- C. The patient maintains their balance while using the walker.
- D. The patient walks with their back hunched over.
Correct answer: A
Rationale: The correct answer is A because advancing the walker too far ahead increases the risk of falls, indicating a need for further teaching. Choice B is correct as using the walker to assist in standing is a proper use. Choice C is correct as maintaining balance while using the walker shows proper technique. Choice D is incorrect as walking with the back hunched over is a posture issue, not directly related to walker use.
3. A nurse observes a colleague not using proper hand hygiene. What should the nurse do first?
- A. Ignore the behavior and continue with care
- B. Discuss the behavior with other colleagues
- C. Confront the colleague about the behavior
- D. Report the behavior to the supervisor
Correct answer: D
Rationale: The correct action for the nurse to take first is to report the behavior to the supervisor. Proper hand hygiene is essential in preventing the spread of infections in healthcare settings. By reporting the observed behavior to the supervisor, the nurse is prioritizing patient safety and promoting a culture of accountability. Ignoring the behavior (Choice A) can put patients at risk, discussing it with other colleagues (Choice B) may not address the issue effectively, and confronting the colleague directly (Choice C) might not be the most appropriate initial step and could lead to conflicts rather than a constructive resolution.
4. What is the priority intervention for a patient experiencing chest pain?
- A. Administer nitroglycerin as prescribed.
- B. Encourage the patient to take deep breaths.
- C. Monitor the patient's blood pressure closely.
- D. Encourage the patient to rest in a comfortable position.
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin as prescribed. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow, addressing the immediate concern of chest pain. Encouraging deep breaths may not be appropriate for chest pain, monitoring blood pressure, although important, is not the priority when the patient is experiencing chest pain, and while resting in a comfortable position is beneficial, administering nitroglycerin is the priority intervention to address the chest pain.
5. The client has a do-not-resuscitate (DNR) order. The family asks the nurse to ignore the DNR if the client codes. What is the nurse's responsibility?
- A. Follow the family's wishes
- B. Explain that the DNR must be honored
- C. Ignore the DNR and proceed with CPR
- D. Perform CPR if the client codes
Correct answer: B
Rationale: The correct answer is B: 'Explain that the DNR must be honored.' The nurse's responsibility is to follow the DNR order, as it is a legal and ethical obligation. Choice A is incorrect because following the family's wishes would go against the established DNR order. Choice C is incorrect as ignoring the DNR order is not appropriate. Choice D is also incorrect as performing CPR would be contrary to the client's expressed wishes in the DNR order.
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