ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is preparing medications for a client via nasogastric tube. What should the nurse do before administering the medications?
- A. Flush the tube with water and administer all medications at once
- B. Administer medications one after the other without flushing
- C. Crush all medications and mix them together for administration
- D. Administer medications in liquid form only
Correct answer: B
Rationale: Before administering medications through a nasogastric tube, the nurse should administer them one after the other without flushing. Flushing the tube with water should be done before and after each medication to prevent any interactions and ensure each medication is delivered effectively. The correct answer is not to administer all medications at once (choice A) as this can lead to potential drug interactions. Crushing all medications and mixing them together (choice C) is incorrect as each medication should be given separately to maintain their individual efficacy. Administering medications in liquid form only (choice D) is limiting and may not be suitable for all types of medications that need to be administered.
2. A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?
- A. Increase protein intake
- B. Monitor blood glucose levels frequently
- C. Increase the dose of insulin
- D. Reduce carbohydrate intake
Correct answer: B
Rationale: The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.
3. What is the priority when assessing a patient for possible deep vein thrombosis (DVT)?
- A. Dorsiflex the foot and check for pain.
- B. Measure the calf circumference of both legs.
- C. Check the skin for signs of redness.
- D. Perform a Doppler ultrasound scan.
Correct answer: B
Rationale: The correct answer is to measure the calf circumference of both legs when assessing a patient for possible DVT. An increase in calf circumference in one leg can indicate the presence of a DVT. Option A is incorrect because dorsiflexing the foot and checking for pain are not primary assessments for DVT. Option C is incorrect as redness of the skin may not always be present in cases of DVT. Option D is incorrect as performing a Doppler ultrasound scan is usually done after clinical assessment and to confirm the diagnosis, not as the initial priority assessment.
4. A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
- A. Purulent
- B. Serous
- C. Sanguineous
- D. Serosanguineous
Correct answer: D
Rationale: The correct answer is D, serosanguineous. Serosanguineous drainage is thin, watery, and pale red, indicating a mixture of serous fluid and blood. Choice A (purulent) refers to thick, yellow or green drainage indicating infection. Choice B (serous) is thin, clear drainage. Choice C (sanguineous) is bright red, indicating fresh bleeding.
5. What is the priority action when a patient is experiencing an allergic reaction to a medication?
- A. Monitor the patient's blood pressure every 15 minutes.
- B. Discontinue the medication and notify the healthcare provider.
- C. Administer an antihistamine to reduce symptoms.
- D. Monitor the patient's urine output closely.
Correct answer: B
Rationale: The correct answer is to discontinue the medication and notify the healthcare provider when a patient is experiencing an allergic reaction to a medication. This action is crucial to prevent further harm to the patient. Monitoring blood pressure (choice A) or urine output (choice D) may be important but is not the priority when managing an allergic reaction. Administering an antihistamine (choice C) should only be done after discontinuing the medication and consulting with the healthcare provider.
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