ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A healthcare provider is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The healthcare provider should recommend which of the following foods as the best source of protein to promote wound healing?
- A. One cup of brown rice
- B. One cup of pureed avocado
- C. One cup of lentils
- D. One cup of orange juice
Correct answer: C
Rationale: Lentils are an excellent source of protein, suitable for a vegan diet, and promote wound healing. Brown rice (Choice A) is a carbohydrate-rich food and lacks sufficient protein for wound healing. Pureed avocado (Choice B) is a healthy fat source but low in protein. Orange juice (Choice D) is a source of vitamin C but lacks protein needed for wound healing.
2. A client is preparing for surgery wearing a necklace. What is the appropriate action?
- A. Remove the necklace and place it in a drawer
- B. Tape the necklace to the patient's skin
- C. Ask the patient for permission to lock it in a safe
- D. Ask the family to hold onto the necklace
Correct answer: C
Rationale: The appropriate action when a client is wearing a necklace before surgery is to ask the patient for permission to lock it in a safe. This is in line with hospital policy to secure valuables before entering surgery. Choice A is incorrect because simply placing the necklace in a drawer may not be secure. Choice B is incorrect as taping the necklace to the patient's skin can cause skin irritation and is not a standard practice. Choice D is incorrect because the responsibility for securing valuables typically lies with the healthcare team, not the patient's family.
3. A community nurse is instructing a group of newly licensed nurses about diseases that require airborne precautions. Which of the following diseases should the nurse include?
- A. Rubella
- B. Pertussis
- C. Influenza
- D. Varicella
Correct answer: D
Rationale: The correct answer is D, Varicella. Varicella (chickenpox) is a disease that requires airborne precautions to prevent its spread. Airborne precautions are necessary to prevent transmission of pathogens that remain infectious over long distances when suspended in the air. Rubella, pertussis, and influenza do not require airborne precautions. Rubella and pertussis require droplet precautions, while influenza requires droplet and contact precautions. Therefore, Varicella is the only disease in the list that necessitates airborne precautions.
4. A nurse manager is asked to select clients for early discharge from the unit following a mass casualty event. Which of the following clients should the nurse manager recommend?
- A. A client awaiting a screening colonoscopy later that day
- B. A client whose discharge was cancelled the prior day because they developed respiratory distress
- C. A client who is 6 hr postoperative following an open cholecystectomy
- D. A client who is prescribed gastric lavage treatments to treat acute aspirin toxicity
Correct answer: A
Rationale: The nurse manager should recommend the client awaiting a screening colonoscopy later that day for early discharge following a mass casualty event. This client is stable and not in immediate need of hospital care. Choices B, C, and D involve clients who require ongoing monitoring and care due to recent developments or treatments, making them unsuitable for early discharge during a mass casualty event.
5. When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?
- A. Check for respiratory depression.
- B. Assess pain control.
- C. Check the infusion site for complications.
- D. Monitor the client's blood pressure.
Correct answer: A
Rationale: The correct answer is to check for respiratory depression first when assessing a client receiving a continuous intravenous infusion of morphine sulfate. Respiratory depression is the most common life-threatening side effect associated with morphine administration. Monitoring respiratory status is crucial as it can quickly deteriorate, leading to serious complications or even respiratory arrest. Assessing pain control (choice B) is important but ensuring adequate ventilation takes precedence. Checking the infusion site for complications (choice C) and monitoring blood pressure (choice D) are also essential aspects of care but are secondary to evaluating respiratory status when administering morphine.
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