ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?
- A. Apply a dressing to the ulcer.
- B. Reposition the patient every 2 hours.
- C. Provide the patient with pain medication.
- D. Clean the ulcer with normal saline.
Correct answer: B
Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.
2. How should a healthcare provider respond when a patient expresses concerns about the side effects of a prescribed medication?
- A. Reassure the patient that side effects are rare.
- B. Discuss the benefits and risks of the medication with the patient.
- C. Encourage the patient to speak to the pharmacist.
- D. Refer the patient to another healthcare provider for information.
Correct answer: B
Rationale: When a patient expresses concerns about medication side effects, it is crucial for the healthcare provider to discuss the benefits and risks of the medication with the patient. This approach helps the patient make an informed decision about their treatment. Choice A is incorrect because dismissing the patient's concerns by reassuring them that side effects are rare may not address the patient's specific worries. Choice C, while pharmacists can provide valuable information, the primary responsibility lies with the healthcare provider. Choice D is incorrect as referring the patient to another healthcare provider may disrupt continuity of care and not address the patient's concerns effectively.
3. When administering a subcutaneous injection of insulin to a client, what angle should the nurse use for the injection?
- A. 45-degree angle
- B. 60-degree angle
- C. 90-degree angle
- D. 30-degree angle
Correct answer: C
Rationale: The correct angle for administering a subcutaneous injection, such as insulin, is 90 degrees. This angle allows for the medication to be delivered into the subcutaneous layer of tissue beneath the skin. A 45-degree angle is typically used for administering subcutaneous injections in infants or those with reduced adipose tissue, while a 60-degree angle is commonly used for intramuscular injections. A 30-degree angle is not a standard angle for subcutaneous injections.
4. A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?
- A. I will monitor my husband for coughing while he is eating
- B. I will monitor my husband for pocketing food in his mouth
- C. I will monitor for a change in my husband's voice after he swallows
- D. I will monitor my husband for tilting his head forward when he swallows
Correct answer: D
Rationale: The correct answer is D. Tilting the head forward during swallowing is not a compensatory technique for dysphagia and may increase the risk of aspiration. Choices A, B, and C are correct statements indicating appropriate monitoring for manifestations of dysphagia: coughing while eating, pocketing food in the mouth, and changes in voice after swallowing are all signs that should be monitored.
5. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?
- A. Do not change the mask if the nurse is comfortable.
- B. Change the mask when relieved by the next shift.
- C. Apply a new mask.
- D. Reapply the mask after it air-dries.
Correct answer: C
Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.
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