ATI RN
ATI Capstone Comprehensive Assessment B
1. If a client refuses surgery, but the family insists, what should the nurse do in this situation?
- A. Respect the family's decision and proceed with the surgery.
- B. Respect the client's decision and notify the healthcare provider.
- C. Try to mediate between the family and the client.
- D. Encourage the client to follow their family's wishes.
Correct answer: B
Rationale: In this situation, the nurse should respect the client's decision and notify the healthcare provider. The client has the right to refuse treatment, and the nurse must advocate for the client's autonomy. Proceeding with the surgery against the client's wishes would violate their autonomy and ethical principles. Trying to mediate between the family and the client may be appropriate, but ultimately, the client's decision should be respected. Encouraging the client to follow their family's wishes disregards the client's autonomy and is not ethically appropriate.
2. How should a healthcare professional manage a patient with a chest tube?
- A. Ensuring the chest tube is secured properly and functioning
- B. Checking for air leaks and ensuring drainage is working
- C. Ensuring chest tube drainage is below chest level
- D. Ensuring proper documentation of chest tube output
Correct answer: D
Rationale: Proper documentation of chest tube output is crucial in the care of a patient with a chest tube. While ensuring the chest tube is secured and functioning, checking for air leaks, and maintaining drainage below chest level are important aspects of care, documentation of output is essential for monitoring the patient's condition, assessing the effectiveness of treatment, and ensuring appropriate interventions if needed.
3. 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.
4. What are the complications of diabetes mellitus that a nurse should monitor for?
- A. Peripheral neuropathy and retinopathy
- B. All of the above
- C. Diabetic ketoacidosis and hyperosmolar hyperglycemic state
- D. Nephropathy and cardiovascular disease
Correct answer: D
Rationale: The correct answer is D. Complications of diabetes mellitus that a nurse should monitor for include nephropathy and cardiovascular disease, in addition to diabetic ketoacidosis, hyperosmolar hyperglycemic state, neuropathy, and retinopathy. While choices A and C mention some complications of diabetes, they do not cover all the complications that a nurse should monitor for. Choice B is incorrect as it suggests selecting all options, which is not accurate.
5. Which of the following actions is a means of maintaining medical asepsis to reduce and prevent the spread of microorganisms?
- A. Sterilizing contaminated items
- B. Routinely cleaning the hospital environment
- C. Reapplying a sterile dressing
- D. Applying a sterile gown and gloves
Correct answer: A
Rationale: The correct answer is A: Sterilizing contaminated items. Maintaining medical asepsis involves ensuring that items are free of microorganisms to prevent infections. Sterilizing contaminated items is a crucial step in this process as it eliminates all microorganisms, including spores. Choices B, C, and D do not directly address the process of reducing and preventing the spread of microorganisms. While routinely cleaning the hospital environment is important for cleanliness, it does not guarantee the elimination of all microorganisms. Reapplying a sterile dressing and applying a sterile gown and gloves are specific actions related to personal protective equipment and wound care, not the general maintenance of medical asepsis.
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