ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?
- A. Loud volume of the television set
- B. Wall-to-wall carpet in the living room
- C. Low chairs without armrests
- D. Use of indirect lighting
Correct answer: C
Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.
2. A nurse is presenting educational materials for a group of middle-aged clients about menopausal hormone therapy following a total hysterectomy. Which of the following information should the nurse include?
- A. Take at different times of the day
- B. Prevents from having a cerebral hemorrhage
- C. Prevents osteoporotic fractures
- D. Take an extra dose if missed a day
Correct answer: C
Rationale: The correct information the nurse should include is that menopausal hormone therapy helps prevent osteoporotic fractures by maintaining bone density. Option A is incorrect as hormone therapy should be taken consistently at the same time each day for optimal effectiveness. Option B is incorrect as menopausal hormone therapy is not primarily aimed at preventing cerebral hemorrhage. Option D is incorrect because taking an extra dose is not recommended if a dose is missed; instead, the missed dose should be taken as soon as remembered, unless it is close to the time for the next dose.
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. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?
- A. Use sterile gloves during the procedure.
- B. Clean the catheter insertion site with alcohol.
- C. Insert the catheter as quickly as possible.
- D. Use a smaller catheter size to minimize trauma.
Correct answer: A
Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.
5. A client was exposed to anthrax. Which of the following antibiotics should be administered?
- A. Fluconazole
- B. Tobramycin
- C. Ciprofloxacin
- D. Vancomycin
Correct answer: C
Rationale: The correct answer is Ciprofloxacin. Ciprofloxacin is an antibiotic effective in treating anthrax exposure. Fluconazole (Choice A) is an antifungal medication used for fungal infections, not anthrax. Tobramycin (Choice B) is an antibiotic used for bacterial infections but is not the first line of treatment for anthrax. Vancomycin (Choice D) is also an antibiotic, but it is not the preferred choice for treating anthrax.
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