ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A nurse is providing teaching to the parent of a child who is receiving oral nystatin for oral candidiasis. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will mix the medication with applesauce
- B. I will provide a snack with the medication
- C. I will store the medication in the refrigerator
- D. I will swab the inside of my child's mouth with the medication
Correct answer: D
Rationale: The correct answer is D because swabbing the inside of the child's mouth with the nystatin solution is the correct administration method for treating oral candidiasis. Mixing the medication with applesauce or providing a snack with it is not the recommended method of administration. Storing the medication in the refrigerator is also unnecessary and not part of the proper administration instructions.
2. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?
- A. Measure and document the urine in the drainage bag
- B. Remove the tape or device securing the catheter to the client's thigh
- C. Position the client supine
- D. Deflate the catheter balloon using a sterile syringe
Correct answer: A
Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.
3. A patient is prescribed a diuretic for hypertension. What is the most important assessment the nurse should perform?
- A. Monitor the patient's respiratory rate.
- B. Check the patient's blood pressure regularly.
- C. Monitor the patient's potassium levels.
- D. Monitor the patient's sodium levels.
Correct answer: D
Rationale: Corrected Rationale: When a patient is prescribed a diuretic for hypertension, monitoring the patient's sodium levels is crucial. Diuretics can lead to alterations in sodium levels, potentially causing complications like hyponatremia. While monitoring other parameters like respiratory rate, blood pressure, and potassium levels may also be important, the primary concern with diuretic therapy is the risk of sodium imbalance, making the monitoring of sodium levels the most critical assessment.
4. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?
- A. Ensure the client is on seizure precautions.
- B. Educate the client about seizure triggers.
- C. Monitor for signs of an impending seizure.
- D. Initiate IV access for anti-seizure medication.
Correct answer: A
Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.
5. Which of the following is the correct method to reduce the risk of infection when handling a urinary catheter?
- A. Clean the catheter tubing with soap and water.
- B. Maintain sterile technique when inserting the catheter.
- C. Insert the catheter using clean gloves and a clean technique.
- D. Flush the catheter tubing regularly with sterile water.
Correct answer: B
Rationale: The correct method to reduce the risk of infection when handling a urinary catheter is to maintain sterile technique when inserting the catheter. Sterile technique helps prevent introducing pathogens into the urinary system, reducing the risk of infection. Choice A is incorrect because cleaning the catheter tubing with soap and water is not sufficient for preventing infection. Choice C is incorrect as clean gloves and technique are not enough; sterile technique is necessary. Choice D is incorrect as flushing the catheter tubing with sterile water, though important for maintaining catheter patency, does not address the need for sterile technique during insertion to prevent infection.
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