ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is preparing to administer medication to a client by nasogastric tube. What should the nurse do first?
- A. Administer the medication without further assessment.
- B. Check the tube placement before administering any medication.
- C. Administer the medication in liquid form only.
- D. Administer half the dosage as a precaution.
Correct answer: B
Rationale: The correct answer is B: Check the tube placement before administering any medication. Before administering medication through a nasogastric tube, the nurse must first verify the tube's correct placement to ensure the medication reaches the stomach and to prevent complications such as aspiration. Options A, C, and D are incorrect because administering medication without confirming proper tube placement can lead to serious consequences for the client.
2. After placing the patient back in bed, what should the nurse do next?
- A. Re-assess the patient.
- B. Complete an incident report.
- C. Notify the health care provider.
- D. Do nothing, no harm has occurred.
Correct answer: C
Rationale: After placing the patient back in bed, the nurse should notify the health care provider. This is important because the health care provider needs to be informed of the incident and assess the patient further to ensure no underlying injuries or issues exist. Re-assessing the patient is crucial but notifying the health care provider takes precedence in this situation. Completing an incident report is important for documentation purposes but not the immediate next step. Doing nothing is incorrect as there was an incident involving a fall that needs further evaluation.
3. A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
- A. Oral mucosa
- B. Conjunctivae
- C. Soles of the feet
- D. Ear lobes
Correct answer: A
Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.
4. A hospice nurse is providing teaching to a client who has a new diagnosis of a terminal illness and her family. Which of the following statements should the nurse include in the teaching?
- A. Hospice care focuses on providing comfort and symptom management.
- B. The provider will coordinate your health care needs while in hospice.
- C. You do not need to choose a family caregiver before being admitted into a hospice facility.
- D. Hospice care continues to help families with grief after a death occurs.
Correct answer: D
Rationale: The correct answer is D because hospice care provides ongoing support to families with grief even after a patient's death. Choice A is incorrect because hospice care focuses on providing comfort and symptom management rather than disease treatment and rehabilitation. Choice B is incorrect as the statement does not accurately reflect the role of a hospice provider. Choice C is incorrect; a family caregiver is not a prerequisite for admission into a hospice facility.
5. A client complains of pain in the leg while in skeletal traction. What is the nurse's priority action?
- A. Increase the pain medication immediately
- B. Check for signs of infection
- C. Reposition the client's leg for comfort
- D. Notify the physician of the client's complaints
Correct answer: B
Rationale: The correct answer is B: Check for signs of infection. In skeletal traction, the priority action for the nurse when a client complains of pain in the leg is to first assess for signs of infection. Pain in skeletal traction can be a symptom of infection or other complications, so checking for signs of infection is crucial before considering other interventions. Increasing pain medication immediately (Choice A) may mask the symptoms of an underlying infection. Repositioning the client's leg for comfort (Choice C) may provide temporary relief but does not address the potential underlying issue. Notifying the physician of the client's complaints (Choice D) is important but assessing for infection should come first to ensure timely and appropriate intervention.
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