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. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?
- A. Positioning the patient in a prone position
- B. Monitoring vital signs and lung sounds
- C. Preparing for mechanical ventilation
- D. Administering supplemental oxygen
Correct answer: A
Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.
3. While assessing a migrant farm worker in a mobile health clinic, which of the following findings should the nurse identify as the priority?
- A. Report of back pain associated with twisting at the waist
- B. Absence of a dental health provider
- C. Lives in a home with 25 other migrant workers
- D. Report of muscle twitching and skin rash
Correct answer: D
Rationale: The correct answer is D because muscle twitching and a rash could indicate pesticide poisoning, a serious condition that requires immediate attention in a migrant farm worker. Option A is not the priority as it could be musculoskeletal in nature and managed after addressing urgent issues. Option B, absence of a dental health provider, though important for overall health, is not an immediate priority. Option C, living with 25 other migrant workers, raises concerns about living conditions but does not present an immediate health threat compared to potential pesticide poisoning.
4. What are the important considerations when administering blood products to a patient?
- A. Ensuring proper documentation of the transfusion
- B. Verifying the patient's identity before administration
- C. Monitoring for allergic reactions or transfusion reactions
- D. Monitoring the patient's vital signs during transfusion
Correct answer: B
Rationale: Verifying the patient's identity before administration is a critical step to ensure that the correct blood product is given to the right patient, thereby preventing transfusion errors. While ensuring proper documentation of the transfusion (choice A) is important for record-keeping, verifying patient identity (choice B) directly addresses the risk of administering blood to the wrong patient. Monitoring for allergic reactions or transfusion reactions (choice C) and monitoring the patient's vital signs during transfusion (choice D) are also essential considerations during blood product administration, but verifying patient identity takes precedence to prevent potentially life-threatening errors.
5. A client with tuberculosis is about to start combination drug therapy. Which of the following medications should the nurse plan to administer? (SATA)
- A. Acyclovir
- B. Pyrazinamide
- C. Isoniazid
- D. Rifampin
Correct answer: B
Rationale: The correct answer is B: Pyrazinamide. In the treatment of tuberculosis, a combination drug therapy is usually employed. Pyrazinamide and rifampin are two key drugs used in this regimen. Acyclovir is an antiviral medication used for herpes infections, not for tuberculosis. Isoniazid is another medication used in tuberculosis treatment, but in this case, the question asked for medications to administer, and the correct choices should be those commonly used in tuberculosis combination therapy.
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