ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A patient is experiencing shortness of breath. What is the nurse's immediate action?
- A. Assist the patient into a high Fowler's position.
- B. Administer oxygen at 2 liters per minute via nasal cannula.
- C. Encourage the patient to take deep breaths and cough.
- D. Assess the patient's lung sounds.
Correct answer: B
Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.
2. A nurse is preparing to administer medication to a client by nasogastric tube. What should the nurse do first?
- A. Administer the medication without further assessment.
- B. Check the tube placement before administering any medication.
- C. Administer the medication in liquid form only.
- D. Administer half the dosage as a precaution.
Correct answer: B
Rationale: The correct answer is B: Check the tube placement before administering any medication. Before administering medication through a nasogastric tube, the nurse must first verify the tube's correct placement to ensure the medication reaches the stomach and to prevent complications such as aspiration. Options A, C, and D are incorrect because administering medication without confirming proper tube placement can lead to serious consequences for the client.
3. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?
- A. Crush all medications and administer them all at once.
- B. Flush the NG tube before and after each medication.
- C. Administer only liquid forms of medications.
- D. Skip flushing the tube entirely.
Correct answer: B
Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.
4. A nurse is preparing to perform a 12-lead electrocardiogram (ECG). Which of the following instructions should the nurse provide to the client?
- A. Remain still once the gel pads are attached
- B. I will be placing electrodes on your chest
- C. I will lower the head of your bed so you can sit up
- D. Breathe normally throughout the procedure
Correct answer: A
Rationale: The correct answer is A. Instructing the client to remain still once the gel pads are attached is crucial to obtaining accurate ECG readings. Choice B is incorrect as electrodes are typically placed on the chest, not the breast. Choice C is incorrect because the client should lie flat during an ECG, not sit up. Choice D is incorrect because the client should breathe normally, rather than holding their breath, throughout the procedure.
5. While working the night shift, a nurse observes a colleague behaving strangely. What is the best course of action?
- A. Ignore the behavior and continue working
- B. Report the behavior to the supervisor
- C. Ask the colleague if everything is okay
- D. Discuss the behavior with other colleagues
Correct answer: B
Rationale: When a nurse observes a colleague behaving strangely, the best course of action is to report the behavior to the supervisor. Unusual behavior by a healthcare professional could compromise patient safety and should be addressed promptly. Ignoring the behavior (Choice A) could potentially lead to negative outcomes for patients. Asking the colleague directly (Choice C) may not be appropriate if the behavior poses a risk. Discussing the behavior with other colleagues (Choice D) may not directly address the issue and could lead to gossip rather than a resolution.
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