ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. When administering a subcutaneous injection of insulin to a client, what angle should the nurse use for the injection?
- A. 45-degree angle
- B. 60-degree angle
- C. 90-degree angle
- D. 30-degree angle
Correct answer: C
Rationale: The correct angle for administering a subcutaneous injection, such as insulin, is 90 degrees. This angle allows for the medication to be delivered into the subcutaneous layer of tissue beneath the skin. A 45-degree angle is typically used for administering subcutaneous injections in infants or those with reduced adipose tissue, while a 60-degree angle is commonly used for intramuscular injections. A 30-degree angle is not a standard angle for subcutaneous injections.
2. A patient has difficulty ambulating after surgery. Which action should the nurse take first?
- A. Encourage deep breathing exercises.
- B. Assist the patient in ambulating a short distance.
- C. Call for assistance with ambulation.
- D. Assess the patient's pain level before ambulation.
Correct answer: C
Rationale: The correct first action for the nurse to take when a patient has difficulty ambulating after surgery is to call for assistance with ambulation. This is essential to ensure the safety of the patient and prevent any potential falls or injuries. Encouraging deep breathing exercises (Choice A) may be beneficial but should not be the first priority when the patient is having difficulty walking. Assisting the patient in ambulating a short distance (Choice B) may put both the patient and the nurse at risk if the patient is struggling. Assessing the patient's pain level before ambulation (Choice D) is important but should come after ensuring that the patient can safely ambulate with assistance.
3. A healthcare provider is assessing a patient with chronic pain. Which finding is most concerning?
- A. The patient reports a pain level of 6 on a scale of 0 to 10.
- B. The patient is lying still and refuses to move.
- C. The patient's pain persists despite medication.
- D. The patient reports feeling anxious and restless.
Correct answer: C
Rationale: In the context of chronic pain management, the most concerning finding is when the patient's pain persists despite medication. This suggests inadequate pain control or the need for a re-evaluation of the treatment plan. Choices A, B, and D are not as concerning in this scenario. A pain level of 6 on a scale of 0 to 10 is moderate and may be manageable with appropriate interventions. Patients with chronic pain can sometimes lie still due to pain or other reasons, and anxiety and restlessness are common in individuals with pain conditions but may not necessarily indicate a critical issue like uncontrolled pain.
4. 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.
5. A nurse is caring for a client who is postoperative and has compression stockings. Which action should the nurse take?
- A. Check the stockings for wrinkles
- B. Apply the stockings while the client is sitting in a chair
- C. Measure the size of the client's foot
- D. Remove the stockings once each day
Correct answer: A
Rationale: The correct action for the nurse to take is to check the stockings for wrinkles. This is important to ensure that the stockings are applied correctly without any folds or wrinkles, which can hinder proper circulation and compression. Option B is incorrect because compression stockings should be applied with the client lying down, not sitting in a chair. Option C is unnecessary as the size of the client's foot is unlikely to change postoperatively. Option D is incorrect as compression stockings are usually worn continuously except for specific care needs.
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