ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?
- A. Crush all medications and administer them all at once.
- B. Flush the NG tube before and after each medication.
- C. Administer only liquid forms of medications.
- D. Skip flushing the tube entirely.
Correct answer: B
Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.
2. A healthcare provider is preparing to administer digoxin to a patient with heart failure. Which of the following lab results should be reviewed before administering the medication?
- A. Potassium level
- B. Calcium level
- C. Hemoglobin level
- D. White blood cell count
Correct answer: A
Rationale: The correct answer is A: Potassium level. Hypokalemia increases the risk of digoxin toxicity. Digoxin can potentiate the effects of low potassium levels, leading to life-threatening arrhythmias. Therefore, it is essential to review the patient's potassium level before administering digoxin. Choices B, C, and D are incorrect because calcium level, hemoglobin level, and white blood cell count are not directly related to the risk of digoxin toxicity.
3. A client complains of pain in their leg, and the nurse notes swelling and pallor. What is the priority nursing action?
- A. Administer pain medication.
- B. Elevate the limb and monitor closely.
- C. Encourage movement to reduce swelling.
- D. Notify the provider immediately about the symptoms.
Correct answer: D
Rationale: The correct answer is D: Notify the provider immediately about the symptoms. Swelling and pallor in a limb can be indicative of serious circulatory issues or compartment syndrome. It is crucial to inform the healthcare provider promptly to assess and address the situation. Administering pain medication (choice A) may temporarily alleviate the symptoms but does not address the underlying cause. Elevating the limb and monitoring closely (choice B) can be beneficial but does not replace the need for immediate professional evaluation. Encouraging movement to reduce swelling (choice C) is contraindicated in this scenario as it may worsen the condition if a circulatory issue or compartment syndrome is present.
4. What are the nursing interventions for a patient with pneumonia?
- A. Providing fluids and rest
- B. Monitoring lung sounds and respiratory rate
- C. Encouraging coughing and deep breathing exercises
- D. Administering antibiotics and providing oxygen therapy
Correct answer: B
Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.
5. In the context of personality disorders, what is a common characteristic of a client with Borderline Personality Disorder?
- A. A need for admiration and a grandiose view of self-importance
- B. Unlawful actions and lack of empathy
- C. Fear of abandonment and impulsiveness
- D. A disregard for others with manipulative behaviors
Correct answer: C
Rationale: The correct answer is C: Fear of abandonment and impulsiveness. Individuals with Borderline Personality Disorder often exhibit intense fears of abandonment, engage in impulsive behaviors such as self-harm or substance abuse, and struggle with unstable relationships. Choices A, B, and D do not align with the characteristic features commonly associated with Borderline Personality Disorder. A need for admiration and grandiosity (Choice A) is more characteristic of Narcissistic Personality Disorder. Unlawful actions and lack of empathy (Choice B) are more typical of Antisocial Personality Disorder. A disregard for others with manipulative behaviors (Choice D) is often seen in individuals with traits of Histrionic or Antisocial Personality Disorders.
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