ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A patient with diabetes is admitted with high blood sugar levels. What is the nurse's priority intervention?
- A. Administer insulin as prescribed.
- B. Encourage the patient to exercise regularly.
- C. Encourage the patient to drink water.
- D. Provide the patient with a low-sugar diet.
Correct answer: A
Rationale: Administering insulin is the priority intervention for a patient admitted with high blood sugar levels because it helps lower the blood sugar levels effectively and rapidly. Insulin is a crucial medication for managing hyperglycemia in diabetes. Encouraging exercise (choice B) can be beneficial in the long term for managing blood sugar levels but is not the most immediate priority. While staying hydrated (choice C) is important, it is not the priority intervention when dealing with high blood sugar levels. Providing a low-sugar diet (choice D) is essential for long-term diabetes management but is not the immediate action needed to address high blood sugar levels in an admitted patient.
2. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?
- A. Uses a sterile bottled solution more than once within a 24-hour period.
- B. Uses surgical aseptic technique to suction an airway.
- C. Uses a clean technique for inserting a urinary catheter.
- D. Uses a cleaning stroke from the urinary meatus toward the rectum.
Correct answer: C
Rationale: The correct answer is C. Using a clean technique for inserting a urinary catheter increases the risk for healthcare-associated infections. Invasive procedures like catheter insertion require a sterile technique to prevent introducing pathogens into the urinary tract. Choices A and B demonstrate appropriate infection control measures by emphasizing the use of sterile or aseptic techniques. Choice D represents an incorrect technique that can lead to the introduction of bacteria from the rectum into the urinary tract, potentially causing infections.
3. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?
- A. Administer the antibiotic immediately
- B. Obtain a sputum culture
- C. Notify the provider of the prescription
- D. Check the client's allergy history
Correct answer: B
Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.
4. A nurse is caring for a female client who has osteoporosis and a new prescription for raloxifene. What should the nurse assess prior to initiating therapy?
- A. Pregnancy status
- B. Bone density
- C. Calcium levels
- D. Blood pressure
Correct answer: A
Rationale: The correct answer is A: Pregnancy status. Raloxifene is a pregnancy category X drug, which means it can cause serious birth defects. Therefore, it is crucial for the nurse to assess the client's pregnancy status before initiating therapy. Choice B, bone density, while important in osteoporosis management, is not a specific concern related to initiating raloxifene therapy. Choice C, calcium levels, and choice D, blood pressure, are not directly related to the initiation of raloxifene therapy in a female client with osteoporosis.
5. A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?
- A. Assess for pain relief.
- B. Monitor for respiratory depression.
- C. Assess the infusion site for complications.
- D. Increase the dosage if the client reports more pain.
Correct answer: B
Rationale: Correct answer: Before administering morphine sulfate, the nurse should monitor for respiratory depression as it is a significant side effect of this medication. Assessing for pain relief (Choice A) is important but not a pre-administration assessment. Checking the infusion site for complications (Choice C) is relevant for IV medications, not specifically for morphine sulfate. Increasing the dosage if the client reports more pain (Choice D) is not appropriate without further assessment and medical orders.
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