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. What are the priority nursing assessments for a patient who has just undergone major surgery?
- A. Providing analgesia as prescribed
- B. Monitoring for signs of infection
- C. Assessing the surgical site for bleeding
- D. Monitoring the patient's vital signs
Correct answer: B
Rationale: The correct answer is to monitor for signs of infection. After major surgery, one of the priority nursing assessments is to watch for signs of infection, such as increased temperature, redness, swelling, or drainage at the surgical site. While providing analgesia is important for pain management, monitoring for infection takes precedence as it can lead to severe complications if not detected early. Assessing the surgical site for bleeding is crucial but is usually more relevant immediately after surgery. Monitoring the patient's vital signs is essential, but the specific focus on infection assessment is crucial in the immediate postoperative period.
3. How should a healthcare professional respond to a patient experiencing hypoglycemia?
- A. Rechecking the blood glucose level in 15 minutes
- B. Encouraging the patient to eat a high-protein snack
- C. Administering 15g of fast-acting carbohydrates
- D. Administering glucagon if the patient is unconscious
Correct answer: C
Rationale: The correct response to a patient experiencing hypoglycemia is to administer 15g of fast-acting carbohydrates. This helps quickly increase the blood glucose levels in the patient, addressing the low blood sugar. Rechecking the blood glucose level in 15 minutes (Choice A) may delay necessary intervention, encouraging a high-protein snack (Choice B) is not recommended as it does not rapidly increase blood sugar levels, and administering glucagon if the patient is unconscious (Choice D) is typically done in severe cases of hypoglycemia when the patient is unable to eat or drink.
4. The healthcare provider is assessing an immobile patient for deep vein thrombosis (DVT). What should the healthcare provider do?
- A. Lightly rub the lower leg to check for redness and tenderness.
- B. Apply elastic stockings every 4 hours.
- C. Measure the calf circumference of both legs.
- D. Flex the foot while assessing for patient discomfort.
Correct answer: C
Rationale: Measuring the calf circumference of both legs is crucial when assessing for DVT in an immobile patient. A significant increase in the circumference of one calf compared to the other suggests the presence of a deep vein thrombosis. Option A is incorrect because rubbing the lower leg may dislodge a clot if present. Option B is incorrect as elastic stockings should not be removed frequently as this can increase the risk of clot formation. Option D is incorrect as dorsiflexing the foot can lead to pain and should not be done to assess for DVT.
5. A client with hypertension is prescribed atenolol. Which of the following findings should the nurse include as adverse effects of this medication?
- A. Cough
- B. Tremor
- C. Constipation
- D. Bradycardia
Correct answer: D
Rationale: Correct. Bradycardia is a known adverse effect of atenolol, a beta-blocker medication commonly used to treat hypertension. Atenolol can slow down the heart rate, leading to bradycardia. The nurse should monitor the client for signs of bradycardia, such as dizziness, fatigue, or fainting. Choices A, B, and C are incorrect because cough, tremor, and constipation are not typically associated with atenolol use.
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