ATI RN
ATI Capstone Comprehensive Assessment B
1. A patient recovering from a stroke has difficulty swallowing. Which action should the nurse prioritize?
- A. Begin feeding the patient soft solids.
- B. Place the patient on NPO (nothing by mouth) status.
- C. Provide ice chips to help soothe the throat.
- D. Start the patient on a clear liquid diet.
Correct answer: B
Rationale: The correct answer is to place the patient on NPO (nothing by mouth) status. Patients recovering from a stroke with difficulty swallowing are at high risk for aspiration, which can lead to serious complications like aspiration pneumonia. Therefore, the priority is to keep the patient on NPO until a thorough evaluation by a healthcare provider is completed. Choice A is incorrect as feeding the patient soft solids can increase the risk of aspiration. Choice C is incorrect as providing ice chips may further compromise swallowing safety. Choice D is incorrect as starting the patient on a clear liquid diet can also increase the risk of aspiration in this scenario.
2. A nurse is preparing an in-service about family violence for a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?
- A. Perpetrators of family-directed violence do not recognize their behavior as abnormal.
- B. Female clients who experience partner violence are at greater risk for chronic diseases.
- C. The victim's risk for homicide is greatest when they decide to leave the relationship.
- D. The level of violence increases over time in abusive relationships.
Correct answer: C
Rationale: The correct answer is C because the risk of homicide increases significantly when a victim decides to leave an abusive relationship. This is a crucial point to emphasize in educating healthcare professionals about family violence. Choice A is incorrect because perpetrators often do not acknowledge their behavior as abnormal. Choice B is incorrect as victims of partner violence are at greater risk for chronic, not acute, diseases. Choice D is incorrect as the level of violence tends to escalate rather than decrease over time in abusive relationships.
3. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?
- A. Confront the nurse about the behavior.
- B. Notify the hospital's safety committee.
- C. Document the observation without addressing it.
- D. Follow up with the nurse at a later time.
Correct answer: B
Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.
4. Which of the following foods is a good source of protein?
- A. Chicken
- B. Tofu
- C. Cheddar cheese
- D. Almonds
Correct answer: C
Rationale: Cheddar cheese is indeed a good source of protein, providing a significant amount per serving. While chicken and tofu are also high in protein, cheddar cheese can be a beneficial source, especially for individuals looking for non-meat options. Almonds, while nutritious, are not as high in protein compared to the other options listed.
5. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
- A. Check for orthostatic hypotension
- B. Use a gait belt
- C. Position the chair on the strong side
- D. Ask for assistance
Correct answer: A
Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.
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