ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?
- A. Monitor the patient's vital signs.
- B. Check the patient's weight daily.
- C. Measure the patient's intake and output.
- D. Monitor the patient's urine color.
Correct answer: B
Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.
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. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?
- A. Provide cognitive-behavioral therapy
- B. Offer frequent orientation and reassurance
- C. Administer a sedative to improve memory recall
- D. Refer the client to a neurologist for further evaluation
Correct answer: B
Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.
4. A case manager at an assisted living facility is reviewing the use of complementary health practices by several clients. Which of the following actions should the case manager plan to take?
- A. Plan to report a client's use of echinacea to the provider as a contraindication to aspirin therapy
- B. Plan to schedule time for a new client to continue tai chi practice as a stress reduction technique
- C. Tell a client that yoga has not been proven effective to reduce manifestations of menopause
- D. Tell a client who drinks cranberry juice daily that it can help treat existing urinary tract infections
Correct answer: B
Rationale: The correct answer is B. Tai chi is a recognized complementary health practice for stress reduction. Scheduling time for a new client to continue tai chi practice aligns with supporting holistic care. Choice A is incorrect because reporting a client's use of echinacea as a contraindication to aspirin therapy is not necessary without further context or evidence of interactions. Choice C is wrong because yoga can indeed be effective in reducing manifestations of menopause. Choice D is also incorrect because while cranberry juice is known to help prevent urinary tract infections, it is not typically used to treat existing infections.
5. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements indicates an understanding of the teaching?
- A. I should avoid taking acetaminophen while taking this medication
- B. I will take this medication at the same time each day
- C. I will need to get my blood tested regularly while taking this medication
- D. I should increase my intake of leafy green vegetables
Correct answer: C
Rationale: The correct answer is C. Warfarin therapy requires regular blood testing to monitor INR levels and ensure therapeutic dosing. Option A is incorrect because acetaminophen can be taken with warfarin. Option B is not specific to warfarin administration. Option D is incorrect as it does not address the key monitoring requirement of blood testing while on warfarin.
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