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. A patient with a history of asthma is admitted with shortness of breath. What is the nurse's priority intervention?
- A. Administer a bronchodilator as prescribed.
- B. Encourage the patient to use an incentive spirometer.
- C. Place the patient in a high Fowler's position.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to administer a bronchodilator as prescribed. This intervention is the priority for a patient with asthma experiencing shortness of breath as it helps relax the airways, making breathing easier. Encouraging the use of an incentive spirometer (Choice B) is beneficial for lung expansion but not the priority in this acute situation. Placing the patient in a high Fowler's position (Choice C) can also help with breathing but is not as immediate as administering a bronchodilator. While monitoring the patient's oxygen saturation closely (Choice D) is important, the immediate action to address the breathing difficulty is administering a bronchodilator.
3. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?
- A. Place the call light within the patient's reach.
- B. Apply a yellow fall risk bracelet to the patient.
- C. Assist the patient when ambulating.
- D. Ensure the patient's room is well-lit.
Correct answer: B
Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.
4. A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?
- A. Amphotericin B
- B. Amoxicillin-clavulanate
- C. Erythromycin
- D. Gentamicin
Correct answer: B
Rationale: Amoxicillin-clavulanate is related to penicillin, and a cross-sensitivity could occur, so the provider should be consulted.
5. 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.
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