ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?
- A. Wear gloves when entering the patient's room.
- B. Place the patient in a private room.
- C. Use a dedicated blood pressure cuff for the patient.
- D. Dispose of all equipment in a biohazard bag.
Correct answer: A
Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.
2. A family was referred to crisis intervention services after a natural disaster. One family member refuses to attend, stating, 'No way, I'm not crazy.' What is the nurse's best response?
- A. Don't worry now. The psychiatrists are well trained to help.
- B. Many times, disasters can create mental health problems, so you really should participate with your family.
- C. This will help your family communicate better.
- D. Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.
Correct answer: D
Rationale: The nurse should reassure the family member that seeking help does not imply mental illness, but is part of coping with the disaster.
3. A healthcare provider writes a prescription for a medication dose three times the normal range. What should the nurse do?
- A. Administer the medication as prescribed
- B. Question the prescription with the provider
- C. Consult with the pharmacist about the dosage
- D. Delay the medication until verification can be made
Correct answer: B
Rationale: The correct action for the nurse in this situation is to question the prescription with the provider. Administering a medication dose three times the normal range without clarification could pose serious risks to the client. Consulting with the pharmacist about the dosage or delaying the medication until verification can be made are not the initial steps to take; the nurse should first clarify the prescription with the healthcare provider to ensure patient safety.
4. A client has urinary incontinence, and the nurse is caring for them. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
- A. Request a prescription for the insertion of an indwelling urinary catheter
- B. Check the client's skin every 8 hours for signs of breakdown
- C. Apply a moisture barrier ointment to the client's skin
- D. Clean the client's skin and perineum with hot water after each episode of incontinence
Correct answer: C
Rationale: The correct action to prevent skin breakdown in a client with urinary incontinence is to apply a moisture barrier ointment to the skin. This ointment helps protect the skin from the harmful effects of moisture exposure, reducing the risk of breakdown. Requesting an indwelling urinary catheter (Choice A) should not be the first-line intervention for skin breakdown prevention. Checking the client's skin for signs of breakdown (Choice B) is important but not as effective as applying a moisture barrier. Cleaning the skin with hot water (Choice D) can actually be detrimental as hot water can strip the skin of its natural oils and worsen skin integrity.
5. A client is preparing for surgery wearing a necklace. What is the appropriate action?
- A. Remove the necklace and place it in a drawer
- B. Tape the necklace to the patient's skin
- C. Ask the patient for permission to lock it in a safe
- D. Ask the family to hold onto the necklace
Correct answer: C
Rationale: The appropriate action when a client is wearing a necklace before surgery is to ask the patient for permission to lock it in a safe. This is in line with hospital policy to secure valuables before entering surgery. Choice A is incorrect because simply placing the necklace in a drawer may not be secure. Choice B is incorrect as taping the necklace to the patient's skin can cause skin irritation and is not a standard practice. Choice D is incorrect because the responsibility for securing valuables typically lies with the healthcare team, not the patient's family.
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