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 healthcare provider is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The healthcare provider should recommend which of the following foods as the best source of protein to promote wound healing?
- A. One cup of brown rice
- B. One cup of pureed avocado
- C. One cup of lentils
- D. One cup of orange juice
Correct answer: C
Rationale: Lentils are an excellent source of protein, suitable for a vegan diet, and promote wound healing. Brown rice (Choice A) is a carbohydrate-rich food and lacks sufficient protein for wound healing. Pureed avocado (Choice B) is a healthy fat source but low in protein. Orange juice (Choice D) is a source of vitamin C but lacks protein needed for wound healing.
3. A nurse is assigned to care for a client with unstable blood pressure. What should the nurse do first?
- A. Monitor the client every two hours.
- B. Continuously monitor the client's vital signs.
- C. Wait for the healthcare provider to provide instructions.
- D. Ask the healthcare provider for specific instructions.
Correct answer: B
Rationale: In the case of a client with unstable blood pressure, the priority action for the nurse is to continuously monitor the client's vital signs. This allows for immediate detection of any fluctuations in blood pressure and timely intervention if necessary. Choice A, monitoring every two hours, may not provide real-time information needed for prompt intervention. Choices C and D suggest waiting for instructions from the healthcare provider, which could cause a delay in addressing the unstable blood pressure, potentially leading to adverse outcomes. Therefore, the most appropriate initial action is to continuously monitor the client's vital signs.
4. A healthcare professional is preparing to administer an intravenous (IV) medication. What action should the healthcare professional take to ensure patient safety?
- A. Ensure the medication is administered at the correct time.
- B. Verify the patient's identification using two identifiers.
- C. Prepare the medication at the healthcare professional's station.
- D. Ensure the medication is administered within 30 minutes of the scheduled time.
Correct answer: B
Rationale: Verifying the patient's identity using two identifiers is crucial to ensure the right patient receives the right medication. This process helps prevent medication errors by confirming the patient's identity through at least two unique identifiers, such as name, date of birth, or medical record number. Choice A is not directly related to ensuring patient safety during medication administration. Choice C is incorrect as medications should be prepared in a sterile environment, not just at the healthcare professional's station. Choice D is not a safe practice as medications should be administered at the scheduled time to maintain therapeutic effectiveness.
5. Which therapeutic technique is recommended for clients with somatic symptom disorder?
- A. Encourage complete bed rest
- B. Limit the amount of time the client spends discussing symptoms
- C. Monitor the client's food intake
- D. Educate the client on lifestyle changes to reduce symptoms
Correct answer: B
Rationale: The correct therapeutic technique recommended for clients with somatic symptom disorder is to limit the amount of time the client spends discussing symptoms. By doing so, the focus can be shifted away from the illness, helping the client to manage their condition better. Encouraging complete bed rest (Choice A) is not typically recommended as it may reinforce illness behaviors. Monitoring the client's food intake (Choice C) may not directly address the psychological aspects of somatic symptom disorder. Educating the client on lifestyle changes (Choice D) is important but may not be as effective initially as limiting symptom-focused discussions.
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