ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?
- A. CT scan
- B. MRI
- C. X-ray
- D. Ultrasound
Correct answer: A
Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.
2. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?
- A. Encourage the patient to take deep breaths.
- B. Assist the patient to sit down slowly.
- C. Instruct the patient to use a walker for support.
- D. Teach the patient how to change positions safely.
Correct answer: B
Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.
3. What is the most appropriate action for handling hazardous drugs?
- A. Wear gloves and wash hands after handling.
- B. Store the drugs according to manufacturer instructions.
- C. Discard unused drugs in regular trash.
- D. Wear personal protective equipment (PPE) when handling hazardous drugs.
Correct answer: D
Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.
4. Which intervention is most effective in preventing deep vein thrombosis (DVT) in a postoperative patient?
- A. Encourage the patient to drink plenty of fluids.
- B. Encourage early ambulation and leg exercises.
- C. Administer anticoagulants as prescribed.
- D. Apply compression stockings to the patient's legs.
Correct answer: B
Rationale: The most effective intervention in preventing deep vein thrombosis (DVT) in a postoperative patient is to encourage early ambulation and leg exercises. Early ambulation helps promote circulation, preventing stasis and reducing the risk of blood clot formation. Encouraging the patient to drink plenty of fluids (choice A) is important for overall health but is not the most effective intervention for preventing DVT. Administering anticoagulants (choice C) is a valuable intervention in some cases, but it may not be suitable for all postoperative patients. Applying compression stockings (choice D) can help prevent DVT but is generally not as effective as early ambulation and leg exercises in postoperative patients.
5. A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?
- A. Administer an antiemetic to the client
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Provide the client with an emesis basin
Correct answer: C
Rationale: Preventing aspiration is the priority when caring for a client who is vomiting to reduce the risk of pneumonia or other respiratory complications. Aspiration can occur when vomitus enters the airway, leading to respiratory distress. Ensuring the airway is protected during vomiting episodes is essential. Administering an antiemetic (Choice A) can be considered after addressing the immediate risk of aspiration. Notifying housekeeping (Choice B) and providing an emesis basin (Choice D) are important but are secondary to preventing aspiration, which is crucial for the client's safety and well-being.
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