ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?
- A. A client who has a right femur fracture with no weight-bearing on the affected leg
- B. A client who has bilateral leg braces due to paralysis of the lower extremities
- C. A client who has bilateral knee replacements with partial weight-bearing on both legs
- D. A client who is able to bear full weight on both lower extremities
Correct answer: A
Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.
2. A health care provider asks the nurse to administer a medication with a dosage significantly higher than usual. What is the nurse's first action?
- A. Administer the medication as ordered.
- B. Question the provider and verify the dose.
- C. Administer half the dosage as a precaution.
- D. Refuse to administer the medication without clarification.
Correct answer: B
Rationale: When a health care provider orders a medication with a dosage significantly higher than usual, the nurse's initial action should be to question the provider and verify the dose. This is crucial to ensure patient safety and prevent medication errors. Administering the medication as ordered (Choice A) without clarification could potentially harm the patient if there was an error in the prescription. Administering half the dosage as a precaution (Choice C) is not a safe practice as it deviates from the prescribed order. Refusing to administer the medication without clarification (Choice D) is important, but the first step should be to seek clarification from the provider to prevent any unnecessary delays in patient care.
3. A healthcare provider is providing a report to a colleague about a client who weighs 210 lb and has a prescription for one-third weight bearing on the right leg. How many kg of weight should the client bear on the right leg?
- A. 32 kg
- B. 35 kg
- C. 40 kg
- D. 45 kg
Correct answer: A
Rationale: To calculate the weight-bearing limit, we first need to convert 210 lbs to kg. To do this, we use the conversion factor 1 lb = 0.453592 kg. So, 210 lbs is equal to 210 * 0.453592 = 95.254 kg. One-third of 95.254 kg is 31.7513 kg, which can be rounded to 32 kg. Therefore, the client should bear 32 kg of weight on the right leg. Choice A is the correct answer. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the client's weight and the prescribed weight-bearing limit.
4. A nurse manager is asked to select clients for early discharge from the unit following a mass casualty event. Which of the following clients should the nurse manager recommend?
- A. A client awaiting a screening colonoscopy later that day
- B. A client whose discharge was cancelled the prior day because they developed respiratory distress
- C. A client who is 6 hr postoperative following an open cholecystectomy
- D. A client who is prescribed gastric lavage treatments to treat acute aspirin toxicity
Correct answer: A
Rationale: The nurse manager should recommend the client awaiting a screening colonoscopy later that day for early discharge following a mass casualty event. This client is stable and not in immediate need of hospital care. Choices B, C, and D involve clients who require ongoing monitoring and care due to recent developments or treatments, making them unsuitable for early discharge during a mass casualty event.
5. A patient is being treated for dehydration. Which lab result would support the diagnosis?
- A. Elevated hemoglobin
- B. Low sodium level
- C. High white blood cell count
- D. Elevated BUN
Correct answer: D
Rationale: Elevated BUN levels are a characteristic finding in dehydration due to reduced kidney perfusion and increased reabsorption of urea. Hemoglobin levels might be elevated in conditions like polycythemia vera, not directly related to dehydration. A low sodium level could be seen in conditions like hyponatremia. A high white blood cell count is more indicative of infection or inflammation rather than dehydration.
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