ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A healthcare provider gives a verbal order for a medication. The nurse is uncomfortable with the order and questions its appropriateness. What should the nurse do?
- A. Refuse to administer the medication and document the refusal.
- B. Clarify the order with the provider before proceeding.
- C. Administer the medication and monitor the patient.
- D. Call a pharmacy consult to discuss the medication.
Correct answer: B
Rationale: The correct action for the nurse to take when uncomfortable with a verbal order for medication is to clarify the order with the provider before proceeding. This ensures patient safety by confirming the appropriateness of the order and prevents any potential harm. Choice A is incorrect because refusing to administer the medication without clarification may delay necessary treatment for the patient. Choice C is incorrect as administering the medication without clarification could pose risks if the order is indeed inappropriate. Choice D is also incorrect as the first step should be direct clarification with the provider before involving others.
2. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?
- A. Change IV solution bags every 36 hr.
- B. Avoid the delegation of hygiene care to assistive personnel (AP)
- C. Wear sterile gloves when removing urinary retention catheters.
- D. Educate staff about the correct use of personal protective equipment (PPE) for isolation precautions
Correct answer: D
Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.
3. A healthcare professional is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the healthcare professional place at the client's bedside?
- A. Defibrillator machine
- B. Chest tube equipment
- C. Central venous catheter tray
- D. Bag-valve-mask device
Correct answer: D
Rationale: Corrected Rationale: A bag-valve-mask device is necessary in case of respiratory complications that may arise due to the effects of the neuromuscular blocking agent. The competitive nature of the agent can lead to muscle weakness, including respiratory muscles, necessitating immediate respiratory support. Placing a defibrillator machine, chest tube equipment, or central venous catheter tray at the client's bedside would not be the priority in this situation. While these items may be important in specific scenarios, ensuring the availability of a bag-valve-mask device is crucial to address potential airway and breathing issues promptly.
4. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?
- A. Do not change the mask if the nurse is comfortable.
- B. Change the mask when relieved by the next shift.
- C. Apply a new mask.
- D. Reapply the mask after it air-dries.
Correct answer: C
Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.
5. A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?
- A. Administer an antiemetic to the client
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Provide the client with an emesis basin
Correct answer: C
Rationale: Preventing aspiration is the priority when caring for a client who is vomiting to reduce the risk of pneumonia or other respiratory complications. Aspiration can occur when vomitus enters the airway, leading to respiratory distress. Ensuring the airway is protected during vomiting episodes is essential. Administering an antiemetic (Choice A) can be considered after addressing the immediate risk of aspiration. Notifying housekeeping (Choice B) and providing an emesis basin (Choice D) are important but are secondary to preventing aspiration, which is crucial for the client's safety and well-being.
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