ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A client complains of pain in their leg, and the nurse notes swelling and pallor. What is the priority nursing action?
- A. Administer pain medication.
- B. Elevate the limb and monitor closely.
- C. Encourage movement to reduce swelling.
- D. Notify the provider immediately about the symptoms.
Correct answer: D
Rationale: The correct answer is D: Notify the provider immediately about the symptoms. Swelling and pallor in a limb can be indicative of serious circulatory issues or compartment syndrome. It is crucial to inform the healthcare provider promptly to assess and address the situation. Administering pain medication (choice A) may temporarily alleviate the symptoms but does not address the underlying cause. Elevating the limb and monitoring closely (choice B) can be beneficial but does not replace the need for immediate professional evaluation. Encouraging movement to reduce swelling (choice C) is contraindicated in this scenario as it may worsen the condition if a circulatory issue or compartment syndrome is present.
2. 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.
3. What is the most important action for the nurse to take before administering digoxin to a patient?
- A. Check the patient's heart rate before administration.
- B. Assess the patient's blood pressure before administration.
- C. Ensure the patient has eaten before administration.
- D. Monitor the patient's weight before administration.
Correct answer: A
Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.
4. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?
- A. Encourage the patient to perform incentive spirometry.
- B. Assist the patient in ambulating around the unit.
- C. Reposition the patient every 2 hours.
- D. Administer pain medication as prescribed.
Correct answer: A
Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.
5. 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.
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