ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A patient is prescribed a diuretic for hypertension. What is the most important assessment the nurse should perform?
- A. Monitor the patient's respiratory rate.
- B. Check the patient's blood pressure regularly.
- C. Monitor the patient's potassium levels.
- D. Monitor the patient's sodium levels.
Correct answer: D
Rationale: Corrected Rationale: When a patient is prescribed a diuretic for hypertension, monitoring the patient's sodium levels is crucial. Diuretics can lead to alterations in sodium levels, potentially causing complications like hyponatremia. While monitoring other parameters like respiratory rate, blood pressure, and potassium levels may also be important, the primary concern with diuretic therapy is the risk of sodium imbalance, making the monitoring of sodium levels the most critical assessment.
2. A healthcare professional is reviewing the medical record of a client who received their medications 1 hour ago. The client reports chest pain. This can be an adverse effect of what medication?
- A. Digoxin
- B. Albuterol
- C. Lisinopril
- D. Metoprolol
Correct answer: B
Rationale: The correct answer is B, Albuterol. Albuterol can cause chest pain as a side effect due to its beta-agonist effects, which can lead to chest discomfort. Digoxin (choice A) is not typically associated with causing chest pain. Lisinopril (choice C) and Metoprolol (choice D) are not known to commonly cause chest pain as a side effect.
3. Which of the following is a critical nursing action when managing a patient with a chest tube?
- A. Keep the chest tube clamped at all times.
- B. Ensure the chest tube is connected to a closed drainage system.
- C. Empty the chest tube drainage system every 2 hours.
- D. Disconnect the chest tube when the patient is ambulating.
Correct answer: B
Rationale: The correct answer is B: "Ensure the chest tube is connected to a closed drainage system." This is a critical nursing action when managing a patient with a chest tube because it is essential for proper drainage and to prevent complications such as air leaks or infections. Option A is incorrect because keeping the chest tube clamped at all times would prevent proper drainage and could lead to complications. Option C is incorrect as emptying the chest tube drainage system should be done based on assessment findings rather than a fixed time interval. Option D is incorrect because disconnecting the chest tube when the patient is ambulating can lead to complications like a pneumothorax.
4. Which intervention reduces reservoirs of infection in a healthcare setting?
- A. Placing capped needles and syringes in puncture-resistant containers
- B. Keeping bedside table surfaces clean and dry
- C. Changing dressings that become wet or soiled
- D. Placing tissues and soiled dressings in paper bags
Correct answer: A
Rationale: Placing capped needles and syringes in puncture-resistant containers is the correct intervention to reduce infection reservoirs in healthcare settings. This practice helps prevent accidental needle-stick injuries and contains potentially infectious materials properly. Keeping bedside table surfaces clean and dry (choice B) is essential for preventing the spread of infections but does not directly address reducing reservoirs of infection. Changing dressings that become wet or soiled (choice C) is important for wound care but does not specifically target infection reservoirs. Placing tissues and soiled dressings in paper bags (choice D) is a proper waste disposal practice but does not directly reduce reservoirs of infection in a healthcare setting.
5. A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?
- A. Diarrhea
- B. Gastric ulcer
- C. Dilated pupils
- D. Dysrhythmias
Correct answer: D
Rationale: The correct answer is D: Dysrhythmias. Straining while defecating can lead to dysrhythmias due to increased vagal stimulation. Choices A, B, and C are incorrect. Straining while defecating is not typically associated with causing diarrhea, gastric ulcers, or dilated pupils.
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