ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is teaching a client who has a new prescription for amoxicillin clavulanate to treat pharyngitis. Which statement indicates understanding?
- A. I will double my dose if I miss one
- B. I should take this medication on an empty stomach between meals
- C. I will take the medication until my sore throat goes away
- D. I will stop taking this medication if I develop itching
Correct answer: C
Rationale: The client should never double the dose if a dose is missed. This can lead to an overdose, which can cause serious adverse effects. Instead, the client should take the next dose as scheduled or consult the provider for guidance.
2. A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?
- A. Monitor the client's intake and output every 6 hours
- B. Administer furosemide to the client
- C. Check the client's IV infusion every 8 hours
- D. Offer the client 240 ml (8 oz) of oral fluids every 4 hours
Correct answer: D
Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.
3. A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?
- A. Urinary output
- B. Pain level
- C. Oxygen saturation
- D. Abdominal dressing
Correct answer: C
Rationale: The correct answer is C: Oxygen saturation. Following abdominal surgery, the priority assessment is to ensure adequate oxygenation. Monitoring oxygen saturation is crucial as the client may be at risk of respiratory complications due to the effects of anesthesia, pain medications, and the surgical procedure itself. Assessing urinary output is important for monitoring kidney function but is not the priority immediately postoperatively. Pain level assessment is essential for the client's comfort but does not take precedence over ensuring oxygen saturation. Checking the abdominal dressing is important for wound assessment, but ensuring adequate oxygenation is the priority in the immediate postoperative period.
4. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?
- A. The nursing student wears gloves when changing bed linens.
- B. The nursing student wears gloves to remove a wound dressing.
- C. The nursing student washes hands after removing gloves.
- D. The nursing student touches the patient's skin with sterile gloves.
Correct answer: D
Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.
5. A client with a new prescription for levothyroxine is receiving teaching from a nurse. Which statement indicates understanding of the teaching?
- A. I should take this with food
- B. I will see immediate results
- C. I might not realize the full effect of the medication for several weeks
- D. I should stop if I feel better
Correct answer: C
Rationale: The correct answer is C: 'I might not realize the full effect of the medication for several weeks.' Levothyroxine is a medication that may take several weeks for the full effect to be evident. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect because immediate results are not expected with levothyroxine. Choice D is incorrect because stopping the medication without consulting a healthcare provider can be harmful, even if the client feels better.
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