ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?
- A. Give detailed information about the medication, including its potential side effects.
- B. Refer the client to the healthcare provider for more information.
- C. Give a brief explanation and administer the medication.
- D. Ask another nurse to explain the medication and proceed.
Correct answer: B
Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.
2. A nurse is preparing a client for surgery. Which of the following actions should be taken first?
- A. Ensure informed consent is signed
- B. Start IV fluids
- C. Administer preoperative antibiotics
- D. Reinforce surgical site dressing
Correct answer: A
Rationale: The correct answer is to ensure informed consent is signed first when preparing a client for surgery. This step is crucial as it ensures that the client has been informed about the procedure, risks, benefits, and alternatives before giving consent. Starting IV fluids (choice B) may be necessary but comes after obtaining informed consent. Administering preoperative antibiotics (choice C) is important but typically follows confirming informed consent. Reinforcing surgical site dressing (choice D) is a postoperative step and does not take precedence over obtaining informed consent.
3. A parent of a child who is terminally ill tells a nurse that she wants to take her child home. Which of the following responses should the nurse make?
- A. Your provider will be here later today.
- B. I can give you information on what that would involve.
- C. I understand how you feel. I felt the same way when my sister was terminally ill.
- D. I think you should speak with social services about your request.
Correct answer: B
Rationale: The nurse should offer to explain the process of taking the child home and provide resources for the parent's decision. Choice B is the best response as it shows willingness to support the parent by offering information on what taking the child home would involve. Choices A, C, and D do not directly address the parent's request or provide the necessary information and support needed in this situation.
4. 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.
5. What is the most important nursing intervention when caring for a patient with a wound?
- A. Apply an occlusive dressing over the wound.
- B. Clean the wound with normal saline.
- C. Administer antibiotics as prescribed.
- D. Reassess the wound every 4 hours for changes.
Correct answer: B
Rationale: The most important nursing intervention when caring for a patient with a wound is to clean the wound with normal saline. This is crucial for preventing infection and promoting healing. Applying an occlusive dressing (Choice A) can be important but should come after cleaning the wound. Administering antibiotics (Choice C) is not the first-line intervention for all wounds and should be based on the healthcare provider's prescription. Reassessing the wound (Choice D) is essential but not the most important initial intervention.
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