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 assessing a client who is postoperative. Which of the following findings should the nurse prioritize?
- A. Elevated temperature
- B. Low blood pressure
- C. Decreased urine output
- D. Increased heart rate
Correct answer: C
Rationale: In a postoperative client, decreased urine output is a crucial finding as it can indicate impaired kidney function or inadequate fluid balance. Prioritizing assessment and intervention for decreased urine output is essential to prevent complications like acute kidney injury. Elevated temperature, low blood pressure, and increased heart rate are also important, but they may not be as urgent or directly related to kidney function in a postoperative client.
3. A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?
- A. Increase dietary intake of raw vegetables
- B. Limit activity
- C. Drink four to five glasses of water daily
- D. Bear down hard when defecating
Correct answer: C
Rationale: The correct instruction the nurse should include is to advise the client to drink four to five glasses of water daily. Increasing water intake helps alleviate constipation by softening stool and increasing bowel movements. Choice A, increasing dietary intake of raw vegetables, can be helpful in preventing constipation but may not be sufficient as the sole intervention for someone already experiencing constipation. Choice B, limiting activity, can worsen constipation as physical activity helps stimulate bowel movements. Choice D, bearing down hard when defecating, can lead to other issues like hemorrhoids and should be avoided.
4. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?
- A. Confront the nurse about the behavior.
- B. Notify the hospital's safety committee.
- C. Document the observation without addressing it.
- D. Follow up with the nurse at a later time.
Correct answer: B
Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.
5. A nurse is planning a staff education program to review nursing interventions for clients who have kidney failure. Which of the following sources should the nurse identify as the best resource for obtaining evidence-based information?
- A. The advice of an expert nephrology nurse
- B. Retrospective chart reviews
- C. Facility critical pathway
- D. A recent peer-reviewed nursing research article
Correct answer: D
Rationale: A peer-reviewed nursing research article is the best resource for obtaining evidence-based information because it provides the most current and reliable data on nursing interventions. Choice A, the advice of an expert nephrology nurse, may be helpful but could be based on individual experience rather than the latest research. Retrospective chart reviews (Choice B) focus on past cases and may not reflect current best practices. Facility critical pathways (Choice C) offer standardized care plans but may not always incorporate the most up-to-date evidence-based practices.
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