ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. After unsuccessful alternatives, a patient requires restraints. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care?
- A. The health care provider writes the type and location of the restraint.
- B. The health care provider renews orders for restraints every 24 hours.
- C. The health care provider performs a face-to-face assessment prior to the order.
- D. The health care provider orders restraints PRN (as needed).
Correct answer: A
Rationale: In the context of restraining a patient, it is crucial for the health care provider to specify the type and location of the restraint in the order to ensure the safety and well-being of the patient. This information helps guide the nursing staff in the safe application of restraints. Renewing orders every 24 hours ensures that the need for restraints is continually assessed, promoting patient safety. Performing a face-to-face assessment before ordering restraints allows for a thorough evaluation of the patient's condition and the necessity of using restraints. Ordering restraints PRN (as needed) is not appropriate for safe care as it lacks specificity and may lead to inconsistent application and monitoring.
2. Which factor places a patient at the highest risk for infection?
- A. A healthy immune system
- B. Presence of chronic illness
- C. Being well-nourished
- D. Age over 65 years
Correct answer: B
Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.
3. Which action by a nurse demonstrates effective communication with a patient?
- A. Providing the patient with written information about their care.
- B. Maintaining eye contact and listening actively to the patient.
- C. Using medical jargon to explain the patient's condition.
- D. Speaking with the patient in a hurried manner to save time.
Correct answer: B
Rationale: Maintaining eye contact and actively listening to the patient is crucial in effective communication as it helps build rapport, shows empathy, and ensures that the patient feels heard and understood. Providing written information can be helpful, but the direct interaction is essential for effective communication. Using medical jargon may confuse the patient instead of clarifying their condition. Speaking hurriedly can make the patient feel rushed and not valued, hindering effective communication.
4. What is the priority action for a patient with a fever?
- A. Administer an antipyretic medication as prescribed.
- B. Assess the patient's temperature regularly.
- C. Provide cooling measures such as a cool compress.
- D. Provide the patient with blankets for comfort.
Correct answer: B
Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.
5. A patient reports nausea and vomiting after chemotherapy. What is the nurse's priority action?
- A. Administer an antiemetic as prescribed.
- B. Encourage the patient to eat small, frequent meals.
- C. Provide the patient with anti-nausea wristbands.
- D. Encourage the patient to rest after eating.
Correct answer: A
Rationale: The correct answer is to administer an antiemetic as prescribed. Chemotherapy-induced nausea and vomiting can be distressing for patients. Administering an antiemetic helps alleviate these symptoms effectively. Choice B, encouraging the patient to eat small, frequent meals, may be helpful for other gastrointestinal issues but is not the priority when the patient is experiencing nausea and vomiting. Choice C, providing anti-nausea wristbands, may offer some relief but is not as direct and immediate as administering an antiemetic. Choice D, encouraging the patient to rest after eating, is not the priority in this situation where the focus should be on managing the nausea and vomiting.
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