ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse notices another nurse skipping hand hygiene. What is the appropriate course of action?
- A. Ignore the situation to maintain team harmony.
- B. Report the behavior to the supervisor.
- C. Discuss the issue with the nurse directly.
- D. Do nothing and continue with patient care.
Correct answer: B
Rationale: Correct hand hygiene is crucial for preventing the spread of infections and ensuring patient safety. When a nurse observes another healthcare worker skipping hand hygiene practices, it is essential to report this behavior to the supervisor. Reporting ensures that appropriate action is taken to address the issue and maintain a safe environment for patients. Ignoring the situation (Choice A) may compromise patient safety. Discussing the issue directly with the nurse (Choice C) may not always be effective in ensuring compliance. Doing nothing and continuing with patient care (Choice D) disregards the importance of infection control protocols.
2. What are the key considerations when administering medication via a nasogastric (NG) tube?
- A. Checking tube placement before administration
- B. Administering medication in liquid form whenever possible
- C. Crushing tablets and mixing them with water if needed
- D. Flushing the NG tube with water before and after medication
Correct answer: A
Rationale: The correct answer is A: Checking tube placement before administration. This is a crucial step to ensure that the medication reaches the stomach safely and does not end up in the lungs, which can lead to serious complications. Choice B is incorrect as not all medications can be administered in liquid form. Choice C is incorrect because crushing tablets can alter their effectiveness or cause harm. Choice D is incorrect as flushing the NG tube with water is not a standard practice before administering medication, unless specified by healthcare provider instructions.
3. A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
- A. Determining the need for restraints
- B. Obtaining an order for a restraint
- C. Assessing the patient's orientation
- D. Applying the restraint
Correct answer: D
Rationale: The correct answer is applying the restraint (Choice D). Nursing assistive personnel can be delegated the task of applying restraints under the supervision and direction of a nurse. Determining the need for restraints (Choice A) and obtaining an order for a restraint (Choice B) involve clinical judgment and assessment, which are responsibilities of the nurse. Assessing the patient's orientation (Choice C) also requires a level of assessment that should be performed by a nurse.
4. A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?
- A. Sit the client upright
- B. Stop the TPN infusion
- C. Turn the client on their left side
- D. Prepare to add insulin to the TPN infusion
Correct answer: B
Rationale: The correct action for the nurse to take when finding that the TPN solution is infusing too rapidly is to stop the TPN infusion. This is crucial to prevent fluid overload and ensure the client's safety. Sitting the client upright (Choice A) or turning the client on their left side (Choice C) are not appropriate responses to a rapidly infusing TPN solution and do not address the immediate issue of preventing complications from the rapid infusion. Adding insulin to the TPN infusion (Choice D) is not indicated unless specifically prescribed by the healthcare provider for the client's condition. Therefore, the priority action is to stop the TPN infusion to prevent potential harm.
5. A nurse is providing teaching to a parent of a child with celiac disease. Which food choice should the nurse include?
- A. Rice
- B. Barley
- C. Wheat
- D. Rye
Correct answer: A
Rationale: The correct answer is A, Rice. In celiac disease, individuals must avoid gluten-containing foods. Rice is a safe option as it is gluten-free. Barley (choice B), Wheat (choice C), and Rye (choice D) all contain gluten and should be avoided in a celiac diet. Therefore, the nurse should emphasize including rice in the child's diet.
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