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 nurse is completing an assessment of a recently widowed older adult client. He states he is unable to drive and is afraid to cook on the stove. Which of the following community resources should the nurse recommend?
- A. Hospice care
- B. Meals on Wheels
- C. Home health services
- D. American Association of Retired Persons
Correct answer: B
Rationale: The correct answer is B: Meals on Wheels. Meals on Wheels is a community resource that provides food for older adults who are unable to cook for themselves, promoting independence and ensuring proper nutrition. Hospice care (choice A) focuses on providing comfort and support for individuals with life-limiting illnesses; it is not primarily aimed at providing meals. Home health services (choice C) typically involve skilled nursing care and therapy services provided in the home setting, rather than meal delivery. The American Association of Retired Persons (choice D) offers advocacy, support, and resources for older adults but does not directly address the specific needs mentioned in the client's situation.
3. What is the priority action for a patient with a fever?
- A. Administer an antipyretic medication as prescribed.
- B. Assess the patient's temperature regularly.
- C. Provide cooling measures such as a cool compress.
- D. Provide the patient with blankets for comfort.
Correct answer: B
Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.
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 patient is at risk for impaired skin integrity. What is the priority intervention for the nurse?
- A. Turn and reposition the patient every 2 hours.
- B. Apply a moisture barrier to the patient's skin.
- C. Massage the patient's skin to promote circulation.
- D. Apply a heating pad to the patient's skin to increase blood flow.
Correct answer: A
Rationale: The correct answer is to turn and reposition the patient every 2 hours. This intervention is crucial in preventing pressure ulcers and maintaining skin integrity by relieving pressure on bony prominences. Applying a moisture barrier (Choice B) is important for moisture-associated skin damage but is not the priority in this case. Massaging the patient's skin (Choice C) can potentially cause friction and shear, increasing the risk of skin breakdown. Applying a heating pad (Choice D) can lead to burns or thermal injuries, exacerbating skin integrity issues.
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