ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client with hypertension is receiving teaching from a healthcare provider. Which statement demonstrates comprehension of the instruction?
- A. I will limit my daily salt intake to 3g
- B. I will discontinue my medication when I start feeling better
- C. I will adhere to a consistent daily medication schedule
- D. I will engage in 60 minutes of exercise every day
Correct answer: C
Rationale: Choice C is the correct answer because taking hypertension medication at the same time each day ensures its effectiveness in managing blood pressure. Consistency in medication intake is crucial to control hypertension. Option A focuses on dietary management, which is essential but not directly related to medication adherence. Option B is incorrect as stopping hypertension medication abruptly can lead to complications. Option D addresses the importance of exercise, which is beneficial for hypertension but not directly related to medication adherence.
2. A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?
- A. Notify the provider
- B. Check the condition of the client
- C. Document the occurrence in the electronic medical record
- D. Complete an incident report
Correct answer: B
Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.
3. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. I should call 911 if my grandchild loses consciousness.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. If my grandchild eats a plant, I should provide syrup of ipecac.
- D. The number for poison control is 800-222-1222.
Correct answer: C
Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.
4. A nurse is assigned to care for a client with unstable blood pressure. What should the nurse do first?
- A. Monitor the client every two hours.
- B. Continuously monitor the client's vital signs.
- C. Wait for the healthcare provider to provide instructions.
- D. Ask the healthcare provider for specific instructions.
Correct answer: B
Rationale: In the case of a client with unstable blood pressure, the priority action for the nurse is to continuously monitor the client's vital signs. This allows for immediate detection of any fluctuations in blood pressure and timely intervention if necessary. Choice A, monitoring every two hours, may not provide real-time information needed for prompt intervention. Choices C and D suggest waiting for instructions from the healthcare provider, which could cause a delay in addressing the unstable blood pressure, potentially leading to adverse outcomes. Therefore, the most appropriate initial action is to continuously monitor the client's vital signs.
5. A patient has a DNR (do-not-resuscitate) order but their family insists on resuscitation if necessary. What should the nurse do?
- A. Follow the family's wishes to resuscitate.
- B. Explain that the nurse must follow the DNR order.
- C. Ask the provider for clarification on the DNR.
- D. Call the ethics committee to discuss the situation.
Correct answer: B
Rationale: The correct answer is B. The nurse must follow the legal DNR order, even if the family insists on resuscitation. Respecting the patient's wishes is crucial in providing ethical care. Choice A is incorrect because the nurse should prioritize the patient's documented wishes over the family's requests. Choice C may cause unnecessary delays in care as the DNR order is a legal document. Choice D is not the initial action to take in this situation; the nurse should first address the conflict between the family's wishes and the patient's DNR order.
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