ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is reviewing the medication orders for a client with heart failure. Which of the following medications should the nurse clarify with the provider?
- A. Furosemide
- B. Spironolactone
- C. Digoxin
- D. Ibuprofen
Correct answer: D
Rationale: The correct answer is D, Ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can worsen heart failure due to its effects on renal function and fluid retention. Therefore, the nurse should clarify the use of Ibuprofen with the provider. Choices A, B, and C (Furosemide, Spironolactone, and Digoxin) are commonly prescribed medications for heart failure that help manage symptoms and improve cardiac function, so they do not need clarification in this scenario.
2. A healthcare provider is planning care for a client who has fluid overload. Which of the following actions should the provider plan to take first?
- A. Assess for edema
- B. Evaluate electrolytes
- C. Restrict fluid intake
- D. Administer diuretics
Correct answer: B
Rationale: Evaluating electrolytes is crucial when addressing fluid overload as it helps determine the severity of the imbalance and guides treatment. Assessing for edema (Choice A) is important but not the priority over evaluating electrolytes. Restricting fluid intake (Choice C) and administering diuretics (Choice D) are interventions that may be necessary but should be based on the electrolyte evaluation to ensure safe and effective care.
3. A patient with a left arm fracture reports severe pain unrelieved by medication. What should the nurse assess for?
- A. Check for compartment syndrome
- B. Increase the pain medication
- C. Prepare the patient for surgery immediately
- D. Administer a sedative to calm the patient
Correct answer: A
Rationale: Correct answer: When a patient with a left arm fracture reports severe pain unrelieved by medication, the nurse should assess for compartment syndrome. Compartment syndrome is a condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. It is a surgical emergency that requires immediate intervention. Choice B is incorrect because simply increasing pain medication without identifying the cause of the unrelieved pain may mask symptoms of a serious issue like compartment syndrome. Choice C is incorrect as surgery would only be necessary if compartment syndrome is confirmed. Choice D is incorrect as administering a sedative does not address the underlying issue of unrelieved pain and may delay appropriate treatment.
4. A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
- A. Elevate the head of the bed no more than 45 degrees
- B. Apply cornstarch to keep sensitive skin areas dry
- C. Massage the skin over the client's bony prominences
- D. Use a transfer device to lift the client up in bed
Correct answer: D
Rationale: The correct answer is to use a transfer device to lift the client up in bed. This intervention helps reduce friction and the risk of skin breakdown, aiding in the prevention of pressure ulcers. Elevating the head of the bed no more than 45 degrees can help with respiratory issues but does not directly address skin integrity. Applying cornstarch may lead to further skin irritation. Massaging over bony prominences can increase the risk of skin damage rather than maintaining skin integrity.
5. What is an appropriate parenting technique for time-out disciplining in children with mental health issues?
- A. Provide positive reinforcement for minor infractions
- B. Remove all privileges for at least one week following a violation
- C. Limit the child's time outside of the home environment
- D. Time-out should only be used in severe situations
Correct answer: B
Rationale: The correct answer is B: 'Remove all privileges for at least one week following a violation.' When dealing with children with mental health issues, it is essential to have consistent consequences for their actions. Providing positive reinforcement for minor infractions (choice A) may not effectively address inappropriate behaviors that require disciplinary action. Limiting the child's time outside the home environment (choice C) does not directly address the behavioral issue. Using time-out only in severe situations (choice D) may not provide consistent consequences for the child's behavior and can lead to escalation before interventions are used.
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