ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A healthcare provider prescribes a higher-than-usual dose of medication. What is the nurse's first action?
- A. Administer the medication and monitor closely.
- B. Hold the medication and consult the pharmacist.
- C. Ask another nurse to verify the dose.
- D. Call the provider for clarification.
Correct answer: D
Rationale: The correct answer is to call the provider for clarification. When faced with a higher-than-usual dose of medication, the nurse's first action should be to contact the prescribing healthcare provider to confirm the dosage. Administering the medication without clarifying the dose with the provider can pose serious risks to the patient's safety. Holding the medication and consulting the pharmacist may be appropriate after contacting the provider for clarification. Asking another nurse to verify the dose is not the most appropriate action when dealing with an unusual prescription; direct communication with the provider is essential in such situations.
2. What are the priority nursing assessments for a patient who has just undergone major surgery?
- A. Providing analgesia as prescribed
- B. Monitoring for signs of infection
- C. Assessing the surgical site for bleeding
- D. Monitoring the patient's vital signs
Correct answer: B
Rationale: The correct answer is to monitor for signs of infection. After major surgery, one of the priority nursing assessments is to watch for signs of infection, such as increased temperature, redness, swelling, or drainage at the surgical site. While providing analgesia is important for pain management, monitoring for infection takes precedence as it can lead to severe complications if not detected early. Assessing the surgical site for bleeding is crucial but is usually more relevant immediately after surgery. Monitoring the patient's vital signs is essential, but the specific focus on infection assessment is crucial in the immediate postoperative period.
3. A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?
- A. Diarrhea
- B. Gastric ulcer
- C. Dilated pupils
- D. Dysrhythmias
Correct answer: D
Rationale: The correct answer is D: Dysrhythmias. Straining while defecating can lead to dysrhythmias due to increased vagal stimulation. Choices A, B, and C are incorrect. Straining while defecating is not typically associated with causing diarrhea, gastric ulcers, or dilated pupils.
4. What are the instructions for a behind-the-ear hearing aid?
- A. Remove before sleeping
- B. Remove before shower
- C. Keep on during all activities
- D. Replace every week
Correct answer: B
Rationale: The correct answer is to remove a behind-the-ear hearing aid before showering to prevent water damage. Choice A is incorrect because it is safe to wear the hearing aid while sleeping as it does not pose a risk of damage. Choice C is incorrect because it is advisable to remove the hearing aid during certain activities to prevent damage or loss. Choice D is incorrect as hearing aids do not need to be replaced weekly unless there is an issue with the device.
5. A patient prescribed warfarin is being taught about dietary restrictions by a healthcare provider. Which of the following foods should the patient be instructed to limit?
- A. Bananas
- B. Spinach
- C. Potatoes
- D. Apples
Correct answer: B
Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which can interfere with the effectiveness of warfarin, an anticoagulant medication. Patients taking warfarin should limit foods high in vitamin K to maintain the medication's effectiveness and consistent dosage. Bananas, potatoes, and apples are not high in vitamin K and do not typically interfere with warfarin therapy.
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