ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?
- A. Choosing a fresh pear would be a good snack option
- B. I should make refried beans for supper
- C. Selecting white rice as a side dish is a good choice
- D. Opting for bran cereal would be a good breakfast choice
Correct answer: C
Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.
2. A client is about to undergo surgery and is unsure about the procedure despite signing the consent. What should the nurse do?
- A. Reassure the client and proceed with the surgery.
- B. Stop the surgery and consult with the surgeon.
- C. Proceed with the surgery but document the client's concerns.
- D. Postpone the surgery until further clarification is provided.
Correct answer: B
Rationale: When a client expresses doubts about a procedure after signing the consent form, it is crucial to stop the surgery and consult with the surgeon. This is important to ensure that the client's concerns are addressed, and there is a clear understanding of the procedure. Reassuring the client and proceeding with the surgery (choice A) may violate the client's autonomy and right to informed consent. Proceeding with the surgery but documenting the concerns (choice C) is not sufficient as the client's doubts should be resolved before proceeding. Postponing the surgery until further clarification is provided (choice D) may be necessary, but the immediate step should be to consult with the surgeon to address the client's concerns.
3. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?
- A. Mild redness at the incision site.
- B. Increased drainage from the surgical site.
- C. Fever of 101°F.
- D. Normal white blood cell count.
Correct answer: C
Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.
4. A nurse is teaching a client about levothyroxine for primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?
- A. Take this medication until your symptoms are gone and then discontinue
- B. Symptoms improve immediately after starting the medication
- C. The medication decreases the overproduction of the thyroid hormone thyroxine
- D. Tremors, nervousness, and insomnia may indicate your dose is too high
Correct answer: D
Rationale: Tremors, nervousness, and insomnia indicate that the dose may be too high, requiring a dose adjustment.
5. A nurse is caring for a patient who has just returned from surgery. What is the nurse's priority action?
- A. Monitor the patient's pain level.
- B. Assess the patient's vital signs.
- C. Assess the surgical incision site.
- D. Position the patient in a high Fowler's position.
Correct answer: B
Rationale: The correct answer is B: Assess the patient's vital signs. Assessing vital signs is crucial as it helps to detect any early signs of complications such as bleeding, shock, or changes in oxygenation. Monitoring the patient's pain level (Choice A) is important but assessing vital signs takes precedence. While assessing the surgical incision site (Choice C) is essential, ensuring the patient's physiological stability through vital sign assessment is the priority. Positioning the patient in a high Fowler's position (Choice D) may be necessary for comfort but does not address the immediate need to assess the patient's condition post-surgery.
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