ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is providing discharge teaching for a client prescribed warfarin. What should be included in the teaching?
- A. Avoid foods rich in vitamin K
- B. Take warfarin with meals
- C. Take aspirin for pain relief
- D. Report unusual bleeding or bruising
Correct answer: D
Rationale: The correct answer is D. When a client is prescribed warfarin, they should be educated to report any unusual bleeding or bruising promptly. Choices A, B, and C are incorrect. Avoiding foods rich in vitamin K is not necessary when taking warfarin, as long as intake remains consistent. Warfarin does not need to be taken with meals, and aspirin should not be taken for pain relief due to its blood-thinning effects, which can increase the risk of bleeding when combined with warfarin.
2. A community health nurse is providing an educational session on childhood poisoning at a local school. What should the nurse advise as the first action if poisoning occurs?
- A. Call the poison control center
- B. Bring the child to the emergency department (ED)
- C. Induce vomiting
- D. Call an ambulance
Correct answer: A
Rationale: In the event of poisoning, the recommended first action is to call the poison control center. Poison control specialists can provide immediate guidance on how to manage the situation effectively. Bringing the child to the emergency department (Choice B) may be necessary depending on the severity of the poisoning, but contacting poison control first is crucial for appropriate and timely intervention. Inducing vomiting (Choice C) is not advised in all cases of poisoning and should only be done under the guidance of healthcare professionals. Calling an ambulance (Choice D) may be necessary in some severe cases, but the initial step should be to contact poison control for expert advice.
3. 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.
4. A nurse in an emergency department is preparing a change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report?
- A. The client has a do-not-resuscitate order.
- B. The client has a continuous IV of lactated Ringer's.
- C. The client was straight catheterized for 350 mL 2 hours ago.
- D. The client has Medicare insurance.
Correct answer: A
Rationale: In an SBAR report, key information such as the client's do-not-resuscitate (DNR) status should be included as it directly impacts the client's care and treatment plan. Choices B and C are important details but may not be as critical for immediate care planning during the shift change. Choice D, the client having Medicare insurance, is important for billing purposes but does not directly impact the client's immediate care needs.
5. How should a healthcare professional assess a patient's pain who is non-verbal?
- A. Looking for changes in vital signs that may indicate pain
- B. Using alternative methods like touch or distraction
- C. Using a pain scale appropriate for non-verbal patients
- D. Observing for facial expressions or other non-verbal cues
Correct answer: A
Rationale: When assessing pain in non-verbal patients, looking for changes in vital signs that may indicate pain is crucial. While using alternative methods like touch or distraction can be helpful, they may not directly indicate the presence of pain. Using a pain scale appropriate for non-verbal patients is important, but it may not always provide immediate feedback. Observing for facial expressions or other non-verbal cues can be subjective and may not always accurately reflect the level of pain the patient is experiencing. Therefore, monitoring vital signs is a more objective way to assess pain in non-verbal patients.
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