ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A healthcare provider orders a medication dose three times higher than usual. What is the nurse's first step?
- A. Administer the medication but monitor the patient closely.
- B. Verify the dosage with the prescribing provider.
- C. Administer a lower dose to minimize the risk.
- D. Hold the medication and wait for further clarification.
Correct answer: B
Rationale: The correct answer is B: Verify the dosage with the prescribing provider. When faced with an unusual medication dose, the nurse's initial action should be to confirm the order with the healthcare provider who prescribed it. This step is crucial to prevent medication errors and ensure patient safety. Choices A, C, and D are incorrect because administering the medication without clarification, administering a lower dose without approval, or holding the medication without consulting the provider can all pose risks to the patient's well-being.
2. A patient with severe pain and leg swelling is admitted. What should the nurse assess for?
- A. Check for signs of deep vein thrombosis.
- B. Assess for compartment syndrome.
- C. Increase the patient's fluid intake.
- D. Prepare the patient for surgery to relieve pain.
Correct answer: B
Rationale: When a patient presents with severe pain and leg swelling, the nurse should assess for compartment syndrome. Compartment syndrome is a serious condition that can develop due to increased pressure within a muscle compartment, leading to compromised circulation and potential tissue damage. It is crucial to identify compartment syndrome promptly as it may require immediate intervention to prevent further complications. Checking for signs of deep vein thrombosis (Choice A) is also important in a patient with leg swelling, but in this scenario, the focus should be on assessing for compartment syndrome due to the severity of the symptoms. Increasing fluid intake (Choice C) may not address the underlying cause of the patient's symptoms. Preparing the patient for surgery (Choice D) without a comprehensive assessment and diagnosis is premature and may not be the appropriate initial intervention.
3. A community nurse is instructing a group of newly licensed nurses about diseases that require airborne precautions. Which of the following diseases should the nurse include?
- A. Rubella
- B. Pertussis
- C. Influenza
- D. Varicella
Correct answer: D
Rationale: The correct answer is D, Varicella. Varicella (chickenpox) is a disease that requires airborne precautions to prevent its spread. Airborne precautions are necessary to prevent transmission of pathogens that remain infectious over long distances when suspended in the air. Rubella, pertussis, and influenza do not require airborne precautions. Rubella and pertussis require droplet precautions, while influenza requires droplet and contact precautions. Therefore, Varicella is the only disease in the list that necessitates airborne precautions.
4. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?
- A. Drink fluids between meals
- B. Eat three large meals each day
- C. Lie down for 30 minutes after meals
- D. Avoid drinking liquids with meals
Correct answer: D
Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.
5. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient?
- A. N95 respirator, gown, gloves, eyewear
- B. Communication signs for droplet precautions
- C. Negative-pressure airflow in room
- D. Communication signs for airborne precautions
Correct answer: A
Rationale: The correct answer is A. Caring for a patient with tuberculosis requires the nurse to use an N95 respirator, gown, gloves, and eyewear to protect against airborne transmission of the disease. Choice B and D are incorrect because while communication signs for precautions are important, the essential items needed for caring for a patient with tuberculosis are personal protective equipment to prevent transmission. Choice C is also incorrect as negative-pressure airflow in the room is a facility-related requirement and not an item carried by the nurse.
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