ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy.
- B. Provide resources for wigs or hairpieces.
- C. Assure the client that hair loss will be minimal.
- D. Offer the client medication to reduce the chances of hair loss.
Correct answer: B
Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.
2. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
- A. Discontinue current medications
- B. Write new prescriptions
- C. Compare prescriptions with the client’s medications
- D. Ask the client to decide
Correct answer: C
Rationale: The correct action in the medication reconciliation process is to compare prescriptions with the client’s medications. This step ensures that there are no conflicting medications prescribed, reducing the risk of adverse drug interactions. Discontinuing current medications or writing new prescriptions without comparing them can lead to errors and potential harm. Asking the client to decide is not appropriate in this context as it is the nurse's responsibility to ensure medication safety based on professional judgment and knowledge.
3. A nurse is caring for a client following an esophagogastroduodenoscopy (EGD). Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Pain
- C. Nausea
- D. Gag reflex
Correct answer: D
Rationale: The correct answer is assessing the gag reflex. This is the priority assessment following an EGD procedure to prevent aspiration. Checking the gag reflex helps ensure the client's airway protection. Assessing the level of consciousness is important, but ensuring the client can protect their airway takes precedence. Pain and nausea assessments are also essential but are secondary to maintaining airway patency.
4. A nurse is evaluating care of an immobilized patient. Which action will the nurse take?
- A. Involve primarily the patient's family and healthcare team to determine goal achievement.
- B. Focus on whether the interdisciplinary team is satisfied with the care.
- C. Use objective data solely to determine whether interventions have been successful.
- D. Compare the patient's actual outcomes with the outcomes in the care plan.
Correct answer: D
Rationale: The correct answer is D because comparing the patient's actual outcomes with the outcomes in the care plan is essential in evaluating the effectiveness of care provided to an immobilized patient. This comparison helps in identifying any disparities between the planned care and the actual care received, allowing the nurse to make necessary adjustments to improve patient outcomes. Choices A, B, and C are incorrect because while involving the patient's family and healthcare team, ensuring interdisciplinary team satisfaction, and using objective data are important aspects of patient care, they do not directly address the specific action needed to evaluate care for an immobilized patient.
5. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?
- A. Place the call light within the patient's reach.
- B. Apply a yellow fall risk bracelet to the patient.
- C. Assist the patient when ambulating.
- D. Ensure the patient's room is well-lit.
Correct answer: B
Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.
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