ATI RN
ATI Capstone Comprehensive Assessment B
1. A healthcare provider is assessing a patient with dehydration. Which finding indicates the patient's condition is worsening?
- A. Dry mucous membranes.
- B. Tachycardia and low blood pressure.
- C. Bradycardia and shallow respirations.
- D. Clear lung sounds.
Correct answer: B
Rationale: Tachycardia and low blood pressure are indicative of worsening dehydration in a patient. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased intravascular volume, while low blood pressure reflects inadequate perfusion due to decreased fluid levels. Bradycardia and shallow respirations are not typical findings in worsening dehydration, and clear lung sounds do not directly correlate with the severity of dehydration.
2. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?
- A. Crush all medications and administer them all at once.
- B. Flush the NG tube before and after each medication.
- C. Administer only liquid forms of medications.
- D. Skip flushing the tube entirely.
Correct answer: B
Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.
3. A nurse is completing an assessment of a recently widowed older adult client. He states he is unable to drive and is afraid to cook on the stove. Which of the following community resources should the nurse recommend?
- A. Hospice care
- B. Meals on Wheels
- C. Home health services
- D. American Association of Retired Persons
Correct answer: B
Rationale: The correct answer is B: Meals on Wheels. Meals on Wheels is a community resource that provides food for older adults who are unable to cook for themselves, promoting independence and ensuring proper nutrition. Hospice care (choice A) focuses on providing comfort and support for individuals with life-limiting illnesses; it is not primarily aimed at providing meals. Home health services (choice C) typically involve skilled nursing care and therapy services provided in the home setting, rather than meal delivery. The American Association of Retired Persons (choice D) offers advocacy, support, and resources for older adults but does not directly address the specific needs mentioned in the client's situation.
4. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?
- A. Monitor the patient's blood pressure regularly.
- B. Change the CVC dressing every 72 hours.
- C. Flush the CVC with normal saline every shift.
- D. Avoid using the CVC for blood draws.
Correct answer: B
Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.
5. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?
- A. Encourage visitors during visiting hours.
- B. Keep the patient on fall precautions until discharge.
- C. Check on the patient every shift.
- D. Raise all four side rails.
Correct answer: B
Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.
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