ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. How can a healthcare provider prevent pressure ulcers in an immobile patient?
- A. Turn the patient every 4 hours.
- B. Provide the patient with a special mattress.
- C. Elevate the patient's legs to reduce pressure.
- D. Limit the patient's movement to reduce friction.
Correct answer: B
Rationale: Providing the immobile patient with a special mattress is an effective way to prevent pressure ulcers. Special mattresses help distribute pressure evenly and reduce the risk of developing pressure ulcers by relieving pressure on sensitive areas. Turning the patient every 4 hours (Choice A) is a standard practice to prevent pressure ulcers but may not be as effective as using a special mattress. Elevating the patient's legs (Choice C) can help with circulation but may not directly prevent pressure ulcers. Limiting the patient's movement (Choice D) can lead to other complications and is not a recommended method for preventing pressure ulcers.
2. A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?
- A. 2
- B. 3
- C. 4
- D. 5
Correct answer: C
Rationale: To calculate the mL needed, divide the total dose by the dose per mL. In this case, 40 mg divided by 10 mg/mL equals 4 mL. Therefore, the nurse should administer 4 mL per dose. Choice A, 2 mL, is incorrect because it would only deliver 20 mg of furosemide, which is half the required dose. Choices B and D are also incorrect as they do not provide the accurate amount needed to achieve the 40 mg dosage.
3. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy.
- B. Provide resources for wigs or hairpieces.
- C. Assure the client that hair loss will be minimal.
- D. Offer the client medication to reduce the chances of hair loss.
Correct answer: B
Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.
4. 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.
5. After surgery, a patient is experiencing pain. What is the nurse's priority action?
- A. Administer pain medication as prescribed.
- B. Assess the patient's pain using a pain scale.
- C. Offer the patient non-pharmacological pain relief methods.
- D. Reassess the patient's pain level after 30 minutes.
Correct answer: B
Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.
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