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. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?
- A. Encourage the patient to perform incentive spirometry.
- B. Assist the patient in ambulating around the unit.
- C. Reposition the patient every 2 hours.
- D. Administer pain medication as prescribed.
Correct answer: A
Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.
3. What is a key component of a comprehensive discharge plan for a patient with heart failure?
- A. Advising on appropriate physical activity and exercise
- B. Fluid restriction to prevent fluid overload
- C. Dietary recommendations, including a low-sodium diet
- D. Medication management, including diuretics and ACE inhibitors
Correct answer: A
Rationale: The main components of a comprehensive discharge plan for a patient with heart failure include advising on appropriate physical activity and exercise to improve cardiovascular health and overall well-being. While fluid restriction and dietary recommendations are important aspects of heart failure management, advising on physical activity and exercise is crucial for improving cardiac function and quality of life post-discharge. Medication management is also essential but focusing on physical activity is particularly relevant for long-term management and preventing readmissions.
4. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?
- A. Patient is lying semiprone.
- B. Patient is lying on side.
- C. Patient is lying on abdomen.
- D. Patient is lying on back.
Correct answer: B
Rationale: The correct answer is B because the lateral position means lying on the side with body weight on the dependent hip and shoulder. Choice A is incorrect as 'semiprone' means lying on the abdomen with one leg flexed. Choice C is incorrect as 'prone' means lying face down. Choice D is incorrect as 'supine' means lying on the back.
5. A patient reports nausea and vomiting after chemotherapy. What is the nurse's priority action?
- A. Administer an antiemetic as prescribed.
- B. Encourage the patient to eat small, frequent meals.
- C. Provide the patient with anti-nausea wristbands.
- D. Encourage the patient to rest after eating.
Correct answer: A
Rationale: The correct answer is to administer an antiemetic as prescribed. Chemotherapy-induced nausea and vomiting can be distressing for patients. Administering an antiemetic helps alleviate these symptoms effectively. Choice B, encouraging the patient to eat small, frequent meals, may be helpful for other gastrointestinal issues but is not the priority when the patient is experiencing nausea and vomiting. Choice C, providing anti-nausea wristbands, may offer some relief but is not as direct and immediate as administering an antiemetic. Choice D, encouraging the patient to rest after eating, is not the priority in this situation where the focus should be on managing the nausea and vomiting.
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