ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. An occupational health nurse is preparing to teach a health promotion class for workers at a warehouse. Which of the following statements should the nurse include?
- A. Rub your hands together for at least 10 seconds when washing them.
- B. Keep your abdominal muscles tightened when lifting objects.
- C. Ensure that 20% or less of calories come from saturated fats.
- D. Engage in aerobic exercise 2 to 4 days per week for 20 minutes.
Correct answer: B
Rationale: The correct statement to include is to 'Keep your abdominal muscles tightened when lifting objects.' This practice helps protect the back from injury by providing core stability. Rubbing hands together for 10 seconds when washing them (Choice A) is a good hygiene practice, but not directly related to warehouse work safety. Ensuring 20% or less of calories come from saturated fats (Choice C) is important for overall health but not specific to workplace safety. Engaging in aerobic exercise 2 to 4 days per week for 20 minutes (Choice D) is beneficial for health but not as directly relevant to preventing injuries while working in a warehouse.
2. When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?
- A. Proceed with the surgery and document the refusal.
- B. Ask the patient for permission to secure the jewelry safely.
- C. Tape the jewelry to the patient's body during surgery.
- D. Tell the patient they must remove the jewelry for safety reasons.
Correct answer: B
Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.
3. A healthcare provider is planning care for a client who has fluid overload. Which of the following actions should the provider plan to take first?
- A. Assess for edema
- B. Evaluate electrolytes
- C. Restrict fluid intake
- D. Administer diuretics
Correct answer: B
Rationale: Evaluating electrolytes is crucial when addressing fluid overload as it helps determine the severity of the imbalance and guides treatment. Assessing for edema (Choice A) is important but not the priority over evaluating electrolytes. Restricting fluid intake (Choice C) and administering diuretics (Choice D) are interventions that may be necessary but should be based on the electrolyte evaluation to ensure safe and effective care.
4. A patient is at risk for impaired skin integrity. What is the priority intervention for the nurse?
- A. Turn and reposition the patient every 2 hours.
- B. Apply a moisture barrier to the patient's skin.
- C. Massage the patient's skin to promote circulation.
- D. Apply a heating pad to the patient's skin to increase blood flow.
Correct answer: A
Rationale: The correct answer is to turn and reposition the patient every 2 hours. This intervention is crucial in preventing pressure ulcers and maintaining skin integrity by relieving pressure on bony prominences. Applying a moisture barrier (Choice B) is important for moisture-associated skin damage but is not the priority in this case. Massaging the patient's skin (Choice C) can potentially cause friction and shear, increasing the risk of skin breakdown. Applying a heating pad (Choice D) can lead to burns or thermal injuries, exacerbating skin integrity issues.
5. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?
- A. Ask the charge nurse for assistance.
- B. Recheck the blood pressure before calling for help.
- C. Monitor the client's blood pressure closely.
- D. Administer antihypertensive medication immediately.
Correct answer: B
Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.
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