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 using the ecologic model for population health to develop interventions to address HIV in a community. Which of the following interventions should the nurse include to address financial factors affecting community health?
- A. Have adolescents lead peer discussions in schools about safe sexual practices
- B. Distribute condoms through remote community clinics
- C. Create commercial advertisements describing the long-term effects of HIV
- D. Include information about perinatal HIV transmission at prenatal education classes
Correct answer: B
Rationale: The correct answer is B. Distributing condoms addresses financial barriers by providing access to essential protective measures in remote areas. Choice A focuses on education rather than direct intervention related to financial factors. Choice C involves advertising and not a direct intervention to address financial factors. Choice D pertains to education about HIV transmission rather than directly addressing financial barriers affecting community health.
3. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?
- A. Restrict the patient's fluid intake.
- B. Monitor the patient's daily weight.
- C. Administer diuretics as prescribed.
- D. Increase the patient's salt intake to promote fluid balance.
Correct answer: B
Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.
4. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?
- A. Report any sign of infection to the provider immediately
- B. Expect your blood pressure to increase
- C. Easy bruising may occur while taking this medication
- D. Muscle rigidity is an expected adverse effect during the first few days of therapy
Correct answer: A
Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.
5. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?
- A. Administer acetaminophen
- B. Stop the transfusion
- C. Slow the transfusion rate
- D. Administer antihistamines
Correct answer: B
Rationale: The correct answer is to stop the transfusion (Choice B). The symptoms described - chills, headache, and low back pain - are indicative of a transfusion reaction. The priority action is to immediately stop the transfusion to prevent further complications such as more severe reactions like hemolytic reactions or anaphylaxis. Administering acetaminophen (Choice A) may help with symptoms but does not address the underlying cause. Slowing the transfusion rate (Choice C) may not be sufficient if a serious transfusion reaction is occurring. Administering antihistamines (Choice D) is not the priority in this situation; stopping the transfusion takes precedence to ensure patient safety.
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