ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?
- A. Administer a diuretic as prescribed.
- B. Place the patient in a high Fowler's position.
- C. Administer oxygen via nasal cannula.
- D. Monitor the patient's lung sounds every 2 hours.
Correct answer: B
Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.
2. A female client with anxiety disorder is being taught about alprazolam by a nurse. Which of the following information should the nurse include in the teaching?
- A. This medication may increase your blood pressure
- B. Use a reliable form of contraception while taking this medication
- C. If a dose is missed, double the next dose of medication
- D. Do not eat aged cheeses while taking this medication
Correct answer: B
Rationale: The correct answer is B. Alprazolam can increase the risk of pregnancy complications, so using a reliable form of contraception is essential to prevent unintended pregnancies. Choice A is incorrect because alprazolam typically does not increase blood pressure. Choice C is incorrect as doubling the next dose after a missed dose can lead to overdose and adverse effects. Choice D is unrelated to alprazolam and is not a concern when taking this medication.
3. Which nursing action is essential when administering a blood transfusion?
- A. Ensure the blood is administered within 4 hours.
- B. Check the patient's vital signs every 30 minutes during the transfusion.
- C. Administer the transfusion at a slow rate for the first 15 minutes.
- D. Document the transfusion in the patient's medical record immediately after administration.
Correct answer: C
Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.
4. What is the most important action for the nurse to take after finding a patient on the floor who reports, 'I fell out of bed'?
- A. Reassess the patient.
- B. Complete an incident report.
- C. Notify the health care provider.
- D. Take no action, as no harm has occurred.
Correct answer: C
Rationale: The most important action for the nurse to take after finding a patient on the floor who reports falling out of bed is to notify the health care provider. This is crucial to ensure that the incident is reported, documented, and that the patient receives necessary follow-up care. Reassessing the patient is important, but notifying the healthcare provider takes precedence to address any potential injuries or issues that may have resulted from the fall. Completing an incident report is necessary, but immediate notification to the healthcare provider is more critical in this situation. Doing nothing is not an appropriate response, as the patient's safety and well-being must be the top priority.
5. A patient with a urinary tract infection (UTI) requires treatment. What is the most appropriate intervention?
- A. Encourage the patient to increase fluid intake.
- B. Administer antibiotics as prescribed.
- C. Recommend the patient take over-the-counter pain relievers.
- D. Encourage the patient to limit physical activity.
Correct answer: B
Rationale: The correct answer is to administer antibiotics as prescribed. Antibiotics are the primary treatment for urinary tract infections as they help eliminate the bacteria causing the infection. Encouraging the patient to increase fluid intake (Choice A) is a supportive measure to help flush out the bacteria but doesn't directly treat the infection. Over-the-counter pain relievers (Choice C) may help with discomfort but do not address the underlying infection. Limiting physical activity (Choice D) may be recommended for some conditions but is not the primary intervention for treating a UTI.
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