ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?
- A. To donate organs, a client must provide consent prior to death
- B. The transplant team will harvest the organs for donation from the donor client
- C. During admission, all clients over the age of 18 should be asked about their organ donor status
- D. The National Organ Transplant Act prohibits the sale and purchase of organs
Correct answer: C
Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.
2. The client has a do-not-resuscitate (DNR) order. The family asks the nurse to ignore the DNR if the client codes. What is the nurse's responsibility?
- A. Follow the family's wishes
- B. Explain that the DNR must be honored
- C. Ignore the DNR and proceed with CPR
- D. Perform CPR if the client codes
Correct answer: B
Rationale: The correct answer is B: 'Explain that the DNR must be honored.' The nurse's responsibility is to follow the DNR order, as it is a legal and ethical obligation. Choice A is incorrect because following the family's wishes would go against the established DNR order. Choice C is incorrect as ignoring the DNR order is not appropriate. Choice D is also incorrect as performing CPR would be contrary to the client's expressed wishes in the DNR order.
3. A client with HIV-1 starting therapy with ritonavir and zidovudine asks why both medications are necessary. What explanation should the nurse provide?
- A. Taking two medications ensures a faster recovery.
- B. The medications work best together to improve your immune system.
- C. Taking the 2 medications together keeps you from becoming resistant to either of them.
- D. These medications target different parts of the virus.
Correct answer: C
Rationale: The correct answer is C because taking two medications together helps prevent the development of drug resistance in HIV treatment. Choice A is incorrect because the primary goal of combination therapy is not necessarily a faster recovery. Choice B is incorrect as the main purpose of combining medications in HIV treatment is to prevent resistance rather than improving the immune system. Choice D is incorrect because while it is true that the medications may target different parts of the virus, the main reason for using both together is to prevent resistance.
4. A community health nurse is reviewing primary prevention strategies for West Nile virus with a group of clients in a rural health clinic. Which of the following instructions should the nurse include?
- A. Avoid exposure to deer ticks.
- B. Eliminate areas of standing water.
- C. Use a respiratory mask when cleaning bird coops.
- D. Plan outdoor activities after dusk.
Correct answer: B
Rationale: The correct answer is B: 'Eliminate areas of standing water.' This is an essential primary prevention strategy for West Nile virus as it helps prevent the breeding of mosquitoes that spread the virus. Choices A, C, and D are incorrect. Avoiding exposure to deer ticks is more relevant for Lyme disease, using a respiratory mask when cleaning bird coops is not a primary prevention strategy for West Nile virus, and planning outdoor activities after dusk does not directly address the prevention of West Nile virus transmission.
5. What are the key components of a pain assessment in a postoperative patient?
- A. Checking the effectiveness of pain interventions
- B. Observing for nonverbal signs of pain like grimacing
- C. Assessing the location, duration, and quality of the pain
- D. Asking the patient to rate their pain on a scale of 1-10
Correct answer: A
Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.
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