ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. 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.
2. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?
- A. Monitor the patient's blood pressure regularly.
- B. Change the CVC dressing every 72 hours.
- C. Flush the CVC with normal saline every shift.
- D. Avoid using the CVC for blood draws.
Correct answer: B
Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.
3. A client complains of pain in the leg while in skeletal traction. What is the nurse's priority action?
- A. Increase the pain medication immediately
- B. Check for signs of infection
- C. Reposition the client's leg for comfort
- D. Notify the physician of the client's complaints
Correct answer: B
Rationale: The correct answer is B: Check for signs of infection. In skeletal traction, the priority action for the nurse when a client complains of pain in the leg is to first assess for signs of infection. Pain in skeletal traction can be a symptom of infection or other complications, so checking for signs of infection is crucial before considering other interventions. Increasing pain medication immediately (Choice A) may mask the symptoms of an underlying infection. Repositioning the client's leg for comfort (Choice C) may provide temporary relief but does not address the potential underlying issue. Notifying the physician of the client's complaints (Choice D) is important but assessing for infection should come first to ensure timely and appropriate intervention.
4. Which of the following is a critical nursing action when managing a patient with a chest tube?
- A. Keep the chest tube clamped at all times.
- B. Ensure the chest tube is connected to a closed drainage system.
- C. Empty the chest tube drainage system every 2 hours.
- D. Disconnect the chest tube when the patient is ambulating.
Correct answer: B
Rationale: The correct answer is B: "Ensure the chest tube is connected to a closed drainage system." This is a critical nursing action when managing a patient with a chest tube because it is essential for proper drainage and to prevent complications such as air leaks or infections. Option A is incorrect because keeping the chest tube clamped at all times would prevent proper drainage and could lead to complications. Option C is incorrect as emptying the chest tube drainage system should be done based on assessment findings rather than a fixed time interval. Option D is incorrect because disconnecting the chest tube when the patient is ambulating can lead to complications like a pneumothorax.
5. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?
- A. Ask the charge nurse for assistance.
- B. Recheck the blood pressure before calling for help.
- C. Monitor the client's blood pressure closely.
- D. Administer antihypertensive medication immediately.
Correct answer: B
Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.
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