ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. What are the instructions for a behind-the-ear hearing aid?
- A. Remove before sleeping
- B. Remove before shower
- C. Keep on during all activities
- D. Replace every week
Correct answer: B
Rationale: The correct answer is to remove a behind-the-ear hearing aid before showering to prevent water damage. Choice A is incorrect because it is safe to wear the hearing aid while sleeping as it does not pose a risk of damage. Choice C is incorrect because it is advisable to remove the hearing aid during certain activities to prevent damage or loss. Choice D is incorrect as hearing aids do not need to be replaced weekly unless there is an issue with the device.
2. While providing care to a group of patients, which patient should the nurse see first?
- A. A patient after knee surgery who needs range of motion exercises
- B. A patient on bed rest who has renal calculi and needs to go to the bathroom
- C. A bedridden patient who has a reddened area on the buttocks who needs to be turned
- D. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
Correct answer: D
Rationale: The nurse should see the patient with a hip replacement experiencing chest pain and dyspnea first because these symptoms could indicate a pulmonary embolism, which is a life-threatening condition requiring immediate attention. The other patients also need care, but urgent assessment and intervention are crucial in the case of potential pulmonary embolism to prevent serious complications or death.
3. What is an expected finding during the assessment of a client transitioning into a new role?
- A. The client's ability to express feelings of guilt
- B. Presence of suicidal or homicidal ideation
- C. Changes in coping skills over the past few weeks
- D. Client's involvement in community activities
Correct answer: B
Rationale: During a client's transition into a new role, the presence of suicidal or homicidal ideation should be assessed due to the increased risk associated with significant life changes. This finding could indicate a need for immediate intervention. While assessing the client's ability to express feelings of guilt is important, it may not be the most critical aspect during this specific assessment. Changes in coping skills over time are relevant but might not be the primary focus during a role transition assessment. The client's involvement in community activities, although beneficial for social support, is not directly related to the immediate concerns of assessing a client transitioning into a new role.
4. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing an acute hemolytic reaction?
- A. Low back pain
- B. Distended neck veins
- C. Chills and fever
- D. Headache
Correct answer: C
Rationale: Chills and fever are classic signs of an acute hemolytic reaction, where the body is reacting to the transfused blood. This reaction can be life-threatening and requires immediate intervention. Low back pain, distended neck veins, and headache are not typical signs of an acute hemolytic reaction. Low back pain may be associated with kidney issues, distended neck veins with fluid overload or heart failure, and headache with various causes such as stress, dehydration, or migraines.
5. What should be done to ensure safety during the transfer of a patient with limited mobility?
- A. Have the patient use a gait belt for support.
- B. Encourage the patient to hold onto a walker.
- C. Lock the wheels on the bed and wheelchair.
- D. Ask the patient to transfer independently.
Correct answer: C
Rationale: The correct answer is to lock the wheels on the bed and wheelchair. This action helps prevent accidents by stabilizing the equipment during the transfer process. Having the patient use a gait belt for support (choice A) can be helpful but is not directly related to equipment safety. Encouraging the patient to hold onto a walker (choice B) is beneficial for ambulation but does not address the safety of equipment. Asking the patient to transfer independently (choice D) can pose risks, especially for a patient with limited mobility, and may not ensure safety during the transfer.
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