ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse caring for a client under airborne precautions notes that the client is scheduled for a nuclear scan. What is the appropriate action for the nurse to take?
- A. Planning to have the nuclear scan performed at the bedside
- B. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued
- C. Asking the technicians in the nuclear scan department to wear masks
- D. Placing a surgical mask on the client for transport and for contact with other individuals
Correct answer: D
Rationale: The correct action for the nurse is to place a surgical mask on the client for transport and for contact with other individuals when a patient under airborne precautions requires movement. This helps prevent the spread of infectious agents. Planning to have the nuclear scan at the bedside (Choice A) may not be feasible or appropriate. Calling the nuclear medicine department to delay the test (Choice B) may inconvenience the client and disrupt the scheduled procedure. Asking technicians in the nuclear scan department to wear masks (Choice C) does not provide adequate protection for others who may come into contact with the client outside the department.
2. A nurse is assigned to care for four clients. Which client should the nurse assess first?
- A. A client with chest pain and shortness of breath
- B. A client with a fever of 100°F
- C. A client scheduled for surgery
- D. A client with stable vital signs
Correct answer: A
Rationale: The correct answer is A. Chest pain and shortness of breath are symptoms that could indicate a life-threatening condition such as a heart attack or pulmonary embolism. Therefore, this client should be assessed first to ensure prompt intervention and treatment. Choice B, a client with a fever of 100°F, may indicate an infection but is not immediately life-threatening compared to the symptoms of chest pain and shortness of breath. Choice C, a client scheduled for surgery, is not an immediate priority unless there are specific preoperative assessments or interventions required. Choice D, a client with stable vital signs, does not indicate an urgent need for assessment compared to the client with chest pain and shortness of breath.
3. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which of the following is a priority nursing intervention?
- A. Administer a dextrose 50% IV bolus
- B. Provide 8 oz of orange juice
- C. Administer regular insulin IV infusion
- D. Give oral metformin
Correct answer: C
Rationale: The correct answer is C: Administer regular insulin IV infusion. In diabetic ketoacidosis (DKA), the priority intervention is to rapidly decrease blood glucose levels. Administering regular insulin via IV infusion helps in lowering blood glucose effectively and quickly. Choice A, administering a dextrose 50% IV bolus, is incorrect because it would further increase blood sugar levels. Choice B, providing orange juice, is not appropriate for treating DKA as it contains sugar that will elevate blood glucose levels. Choice D, giving oral metformin, is not suitable for immediate blood glucose reduction as it acts over time and is not the first-line treatment for DKA.
4. What is the recommended procedure for a healthcare professional to follow when applying sterile gloves?
- A. Use non-sterile gloves first, followed by sterile gloves.
- B. Put on sterile gloves, then gown.
- C. Apply gloves after donning a mask.
- D. Apply gloves before touching any sterile equipment.
Correct answer: D
Rationale: The correct procedure for applying sterile gloves is to do so before touching any sterile equipment or surfaces. This helps maintain the sterility of the gloves. Choices A, B, and C are incorrect because they suggest incorrect sequences that may compromise the sterility of the gloves. Using non-sterile gloves first can introduce contamination, putting on gloves before a gown can lead to contamination of the gloves during gowning, and applying gloves after donning a mask can risk contamination of the gloves from the mask.
5. A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?
- A. Urinary output
- B. Pain level
- C. Oxygen saturation
- D. Abdominal dressing
Correct answer: C
Rationale: The correct answer is C: Oxygen saturation. Following abdominal surgery, the priority assessment is to ensure adequate oxygenation. Monitoring oxygen saturation is crucial as the client may be at risk of respiratory complications due to the effects of anesthesia, pain medications, and the surgical procedure itself. Assessing urinary output is important for monitoring kidney function but is not the priority immediately postoperatively. Pain level assessment is essential for the client's comfort but does not take precedence over ensuring oxygen saturation. Checking the abdominal dressing is important for wound assessment, but ensuring adequate oxygenation is the priority in the immediate postoperative period.
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