ATI RN
ATI Capstone Comprehensive Assessment B
1. A healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?
- A. Fever of 101°F.
- B. Blood pressure of 140/90 mmHg.
- C. Heart rate of 95 beats per minute.
- D. Crackles heard in the lung bases.
Correct answer: D
Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.
2. A nurse is teaching a client about levothyroxine for primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?
- A. Take this medication until your symptoms are gone and then discontinue
- B. Symptoms improve immediately after starting the medication
- C. The medication decreases the overproduction of the thyroid hormone thyroxine
- D. Tremors, nervousness, and insomnia may indicate your dose is too high
Correct answer: D
Rationale: Tremors, nervousness, and insomnia indicate that the dose may be too high, requiring a dose adjustment.
3. A nurse observes a colleague ignoring proper hand hygiene protocols. What should the nurse do first?
- A. Speak to the colleague directly.
- B. Ignore the situation, as it doesn't involve direct patient care.
- C. Report the colleague to the nursing manager.
- D. File an incident report immediately.
Correct answer: D
Rationale: The correct first action for the nurse to take in this situation is to file an incident report immediately. By doing so, the nurse ensures that the unsafe practice is documented for further investigation and corrective action. Speaking to the colleague directly may not address the root cause of the issue and could lead to potential conflicts. Ignoring the situation is not an appropriate response as it compromises patient safety. Reporting the colleague to the nursing manager should be done after filing an incident report to ensure that appropriate actions are taken to prevent future occurrences of non-compliance with hand hygiene protocols.
4. A client has a new prescription for lisinopril. Which of the following statements indicates an understanding of the teaching?
- A. I should take this medication with food
- B. I should report a cough to my provider
- C. I should expect to have facial swelling when taking this medication
- D. I should increase my intake of potassium-rich foods
Correct answer: B
Rationale: The correct answer is B. Reporting a cough is crucial when taking lisinopril as it can be a sign of a serious side effect, such as angioedema or cough associated with ACE inhibitors. Option A is incorrect because lisinopril can be taken with or without food. Option C is incorrect as facial swelling is not an expected side effect of lisinopril. Option D is incorrect because lisinopril can cause hyperkalemia, so increasing potassium-rich foods without healthcare provider guidance can be dangerous.
5. What are the nursing priorities when caring for a patient with a newly placed peripherally inserted central catheter (PICC)?
- A. Performing sterile dressing changes
- B. Educating the patient on PICC line care
- C. Flushing the PICC line as prescribed
- D. Inspecting the insertion site for signs of infection
Correct answer: A
Rationale: The correct answer is A: Performing sterile dressing changes. When caring for a patient with a newly placed PICC line, one of the nursing priorities is to ensure proper care of the insertion site by performing sterile dressing changes. This helps prevent infections and maintain the integrity of the line. While educating the patient on PICC line care, flushing the PICC line as prescribed, and inspecting the insertion site for signs of infection are important aspects of care, the priority immediately after insertion is to maintain the sterility of the site through proper dressing changes.
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