ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A healthcare provider is reviewing a client's lab results. Which of the following lab values should the provider report?
- A. Magnesium 1.9 mEq/L
- B. Potassium 3.6 mEq/L
- C. Sodium 126 mEq/L
- D. Chloride 99 mEq/L
Correct answer: C
Rationale: The correct answer is C: Sodium 126 mEq/L. A sodium level of 126 mEq/L is below the normal range, indicating hyponatremia, which can have serious health implications and should be reported to the healthcare provider for further evaluation and intervention. Choices A, B, and D are within or close to the normal ranges for magnesium, potassium, and chloride, respectively, and do not require immediate reporting as they are not significantly abnormal.
2. A client has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent infection?
- A. Change the catheter every 72 hours.
- B. Ensure the tubing is unkinked.
- C. Empty the drainage bag every 4 hours.
- D. Hang the drainage bag below the bladder.
Correct answer: D
Rationale: The correct answer is to hang the drainage bag below the bladder. This positioning helps prevent backflow of urine, reducing the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may increase infection risk by introducing pathogens. Ensuring the tubing is unkinked promotes proper urine flow but does not directly prevent infection. Emptying the drainage bag regularly is important to prevent urinary stasis but does not directly address infection prevention.
3. Which action by a nurse demonstrates effective communication with a patient?
- A. Providing the patient with written information about their care.
- B. Maintaining eye contact and listening actively to the patient.
- C. Using medical jargon to explain the patient's condition.
- D. Speaking with the patient in a hurried manner to save time.
Correct answer: B
Rationale: Maintaining eye contact and actively listening to the patient is crucial in effective communication as it helps build rapport, shows empathy, and ensures that the patient feels heard and understood. Providing written information can be helpful, but the direct interaction is essential for effective communication. Using medical jargon may confuse the patient instead of clarifying their condition. Speaking hurriedly can make the patient feel rushed and not valued, hindering effective communication.
4. What is the primary purpose of turning and repositioning an immobile patient every 2 hours?
- A. To improve circulation and relieve pressure.
- B. To prevent contractures and muscle atrophy.
- C. To prevent skin breakdown and pressure ulcers.
- D. To improve respiratory function and prevent pneumonia.
Correct answer: C
Rationale: The primary purpose of turning and repositioning an immobile patient every 2 hours is to prevent skin breakdown and pressure ulcers. Prolonged immobility can lead to pressure ulcers, making this a crucial nursing intervention. Choice A is incorrect because while turning can help improve circulation and relieve pressure, the primary purpose is to prevent skin breakdown. Choice B is incorrect as preventing contractures and muscle atrophy is important but not the primary purpose of turning. Choice D is incorrect as improving respiratory function and preventing pneumonia are not directly related to turning and repositioning for skin integrity.
5. A healthcare professional is assessing a client who has a hip fracture. Which of the following findings should the healthcare professional expect?
- A. Hip pallor
- B. Leg abduction
- C. Muscle spasms
- D. Leg lengthening
Correct answer: C
Rationale: Muscle spasms are a common finding in clients with hip fractures. The muscle spasms occur due to the body's natural response to the injury, causing involuntary contractions. Hip pallor (Choice A) is not typically associated with hip fractures. Leg abduction (Choice B) and leg lengthening (Choice D) are not typical findings in clients with hip fractures, as the fracture usually results in limited range of motion and shortening of the affected limb.
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