ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a client who is requesting to leave the facility against medical advice (AMA). The client states, 'I am ready to go immediately.' Which of the following actions should the nurse take first?
- A. Teach the client about the potential health risks of leaving early
- B. Ask the client to sign a document stating they are leaving AMA
- C. Document the client's statement in direct quotes in the medical record
- D. Complete an incident report detailing the client scenario
Correct answer: A
Rationale: The correct action for the nurse to take first is to educate the client about the potential health risks of leaving against medical advice (AMA). By providing this information, the nurse can help the client make an informed decision regarding their healthcare. Choice B, asking the client to sign a document, can be done after the client has been informed about the risks. Choice C, documenting the client's statement, is important but should not take precedence over educating the client. Choice D, completing an incident report, is not the priority when a client is requesting to leave AMA.
2. A healthcare provider is assessing a client who has carpal tunnel syndrome. The provider should expect which of the following findings?
- A. Positive Chvostek's sign
- B. Cool extremities
- C. Positive Phalen's sign
- D. Decreased radial pulse
Correct answer: C
Rationale: Phalen's sign is often positive in clients with carpal tunnel syndrome due to nerve compression. Chvostek's sign (Choice A) is related to hypocalcemia, cool extremities (Choice B) are not typically associated with carpal tunnel syndrome, and decreased radial pulse (Choice D) is not a common finding in carpal tunnel syndrome.
3. A patient with a urinary catheter reports discomfort. What is the nurse's priority action?
- A. Ensure the catheter tubing is not kinked.
- B. Irrigate the catheter to relieve the discomfort.
- C. Change the catheter to a smaller size.
- D. Remove the catheter and replace it with a new one.
Correct answer: A
Rationale: The correct answer is to ensure the catheter tubing is not kinked. This is the priority action because a kinked tubing can obstruct urine flow, leading to discomfort and potential complications. It is essential to troubleshoot the current catheter first before considering other interventions. Irrigating the catheter (Choice B) may not address the underlying issue of kinking. Changing the catheter to a smaller size (Choice C) or removing and replacing it with a new one (Choice D) should only be considered if ensuring the tubing is unkinked does not resolve the discomfort.
4. How should a healthcare provider respond to a patient who is exhibiting signs of acute myocardial infarction (AMI)?
- A. Calling for emergency assistance immediately
- B. Administering nitroglycerin as prescribed
- C. Monitoring the patient's cardiac rhythm
- D. Administering oxygen and preparing for ECG
Correct answer: A
Rationale: When a patient is exhibiting signs of acute myocardial infarction (AMI), the priority action is to call for emergency assistance immediately. This ensures that the patient receives prompt and appropriate care, including interventions such as administering oxygen, nitroglycerin, and monitoring cardiac rhythm. Administering nitroglycerin should only be done if prescribed by a healthcare provider after assessment and confirmation of AMI. Monitoring the patient's cardiac rhythm is important but not the initial action needed in this critical situation. Administering oxygen and preparing for an ECG are important interventions but should follow the immediate step of calling for emergency assistance.
5. What should be done to manage a patient with contact precautions?
- A. Wear a mask, gown, and gloves for all patient interactions.
- B. Ensure that visitors wear protective equipment.
- C. Dedicate all patient care equipment to that patient.
- D. Disinfect shared equipment before use.
Correct answer: C
Rationale: When managing a patient with contact precautions, it is essential to dedicate all patient care equipment to that specific patient. This practice helps minimize the risk of spreading infections to other patients. Choice A, wearing protective gear for all patient interactions, is a general precaution but not specific to managing a patient with contact precautions. Choice B, ensuring visitors wear protective equipment, is important for infection control but not directly related to managing the patient with contact precautions. Choice D, disinfecting shared equipment before use, is a good practice for infection control in general but does not address the specific needs of a patient under contact precautions.
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