ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?
- A. Aspirate for a blood return before depressing the plunger
- B. Insert the needle at a 45-degree angle
- C. Administer the medication 2.54 cm (1 in) from the umbilicus
- D. The nurse should not expel the air bubble in the prefilled syringe
Correct answer: D
Rationale: The correct action when administering enoxaparin is not to expel the air bubble in the prefilled syringe. Expelling the air bubble may lead to the loss of medication and result in an incomplete dose. Aspirating for a blood return (Choice A) is not necessary for subcutaneous injections like enoxaparin. Inserting the needle at a 45-degree angle (Choice B) is not specific to administering enoxaparin. Administering the medication 2.54 cm (1 in) from the umbilicus (Choice C) is not a standard guideline for enoxaparin administration.
2. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP?
- A. The nurse is responsible for providing a safe environment for the patient.
- B. This step is crucial in the process of handwashing.
- C. Different scopes of practice allow for procedure modifications.
- D. Leaving the water running wastes resources and money.
Correct answer: A
Rationale: The correct answer is A. The nurse is responsible for providing a safe environment for the patient. In this situation, the nurse should follow up with the nursing assistive personnel (NAP) who turned off the handle faucet with bare hands to ensure infection control practices are maintained. This action is crucial to prevent the spread of infections in the hospital setting. Choice B is incorrect because the question is not specifically about handwashing procedures but about infection control practices. Choice C is incorrect as it does not address the potential risk of infection transmission. Choice D is incorrect as it is unrelated to the main concern of infection control in this scenario.
3. A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
- A. I will not use hairspray if I am wearing the hearing aids
- B. I will clean the hearing aids with alcohol wipes
- C. I will change the batteries once a week
- D. I will expect the hearing aids to whistle when I cup my hand over them
Correct answer: B
Rationale: The correct answer is B because cleaning the hearing aids with alcohol wipes can damage them. It is important to use specialized cleaning tools or follow specific cleaning instructions provided by the manufacturer to prevent harm to the hearing aids. Choices A, C, and D demonstrate good understanding and appropriate care for hearing aids, indicating that the client does not need further instruction in those areas.
4. A nurse witnesses a colleague administering the wrong IV solution to a client. What should the nurse do first?
- A. Complete an incident report.
- B. Ask the colleague if they intend to report the error.
- C. Call the healthcare provider to notify them of the error.
- D. Notify the supervisor about the situation.
Correct answer: B
Rationale: The correct first step for the nurse to take in this situation is to ask the colleague if they intend to report the error. It is important to address the error promptly and directly with the colleague involved to ensure that the appropriate actions are taken to correct the mistake and prevent harm to the client. Completing an incident report, calling the healthcare provider, or notifying the supervisor can be done after discussing the error with the colleague. Immediate communication with the colleague directly involved in the error is crucial to address the situation effectively.
5. A healthcare provider is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the healthcare provider include in the teaching? (SATA)
- A. Vitamin B12
- B. Vitamin C
- C. Vitamin K
- D. Vitamin D
Correct answer: B
Rationale: The correct answer is Vitamin C. Vitamin C is essential for wound healing due to its role in collagen production. Collagen is crucial for wound repair and the formation of new tissue. Vitamin B12 is important for nerve function and DNA synthesis but is not directly related to wound healing. Vitamin K is essential for blood clotting and bone health but does not directly promote wound healing. Vitamin D plays a role in bone health and immune function but is not a primary vitamin involved in wound healing.
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