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 healthcare provider is caring for a client who has heart failure and is prescribed enalapril. The provider should monitor the client for which of the following adverse effects?
- A. Hypertension
- B. Hypokalemia
- C. Hyperglycemia
- D. Hyperkalemia
Correct answer: D
Rationale: Corrected Question: When a client with heart failure is prescribed enalapril, monitoring for hyperkalemia is essential. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can lead to an increase in potassium levels in the blood. This adverse effect can be serious and potentially life-threatening. Choices A, B, and C are incorrect because enalapril does not typically cause hypertension, hypokalemia, or hyperglycemia as adverse effects. It's essential for healthcare providers to be vigilant in monitoring potassium levels when clients are on ACE inhibitors like enalapril.
3. An occupational health nurse in a factory is planning interventions to reduce environmental stressors for employees. Which of the following interventions should the nurse use to affect physical agents in the environment?
- A. Teach workers to choose personal strategies to cope with work stress
- B. Limit the amount of time workers spend in temperatures over 43.3°C (110°F)
- C. Provide ear plugs for use at workstations throughout the factory
- D. Obtain dosimeters for employees to wear when using new machinery that emits radiation
Correct answer: B
Rationale: Limiting exposure to extreme temperatures is important to protect workers from heat-related illnesses.
4. A healthcare professional is planning care for a client who is scheduled for a lumbar puncture. Which of the following actions should the healthcare professional include?
- A. Restrict the client's fluid intake for 4 hours following the procedure
- B. Apply cold compresses to the puncture site after the procedure
- C. Instruct the client to increase oral fluid intake after the procedure
- D. Keep the client in a prone position for 12 hours after the procedure
Correct answer: C
Rationale: The correct action to include in caring for a client scheduled for a lumbar puncture is to instruct the client to increase oral fluid intake after the procedure. Increasing oral fluid intake helps replace cerebrospinal fluid lost during the lumbar puncture and reduces the risk of headaches. Restricting fluid intake (Choice A) is not recommended as it can lead to dehydration. Applying cold compresses (Choice B) is not necessary after a lumbar puncture. Keeping the client in a prone position for 12 hours (Choice D) is not required after a lumbar puncture and can cause discomfort and complications.
5. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
- A. Hold the cane with your left hand
- B. Move the cane forward 18 inches with each step
- C. When walking, move your left foot forward first
- D. Keep your elbow straight when you hold the cane
Correct answer: C
Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.
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