ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. 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.
2. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
- A. Self-report of pain
- B. Nonverbal behavior
- C. Severity of the condition
- D. Vital signs
Correct answer: A
Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.
3. What are the clinical signs of hyperglycemia in a patient with diabetes mellitus, and how should a nurse respond?
- A. Monitoring blood glucose levels and administering insulin
- B. Polyuria, polydipsia, and polyphagia
- C. Fatigue, blurred vision, and fruity breath
- D. Educating the patient on blood glucose monitoring
Correct answer: B
Rationale: The correct signs of hyperglycemia in a patient with diabetes mellitus are polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). These symptoms indicate high blood sugar levels. Therefore, the correct response for a nurse would be to recognize these signs, monitor blood glucose levels, and administer insulin to manage the hyperglycemia. Choice A is incorrect because it only addresses the response aspect without mentioning the signs. Choices C and D are incorrect as they do not reflect the classic clinical signs of hyperglycemia in diabetes mellitus.
4. After signing an informed consent form, a client states, 'I have changed my mind and do not want to have the procedure.' Which of the following actions should the nurse take?
- A. Suggest that family members discuss the importance of the surgery with the client
- B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure
- C. Document the risks of refusing the procedure in the client's medical record
- D. Discuss the benefits of the procedure with the client
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to notify the surgeon that the client wishes to withdraw informed consent for the procedure. This ensures that the client's right to refuse treatment is respected. Choice A is incorrect because involving family members in this decision could violate the client's autonomy. Choice C is incorrect as it does not address the immediate need to respect the client's decision. Choice D is also incorrect as the client has clearly stated their refusal of the procedure.
5. A patient has a new prescription for allopurinol to treat gout. What should the nurse include in the teaching?
- A. Decrease protein intake
- B. Limit salt intake
- C. Increase fluid intake
- D. Limit alcohol
Correct answer: C
Rationale: Correct answer: Increasing fluid intake is essential when taking allopurinol to prevent kidney stones and aid in uric acid excretion. This helps reduce the risk of developing complications associated with gout. Decreasing protein intake (Choice A) is not directly related to allopurinol therapy. Limiting salt intake (Choice B) and alcohol consumption (Choice D) are important for overall health but are not specific recommendations when taking allopurinol for gout.
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