ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. How should a healthcare professional manage a patient with a chest tube?
- A. Ensuring the chest tube is secured properly and functioning
- B. Checking for air leaks and ensuring drainage is working
- C. Ensuring chest tube drainage is below chest level
- D. Ensuring proper documentation of chest tube output
Correct answer: D
Rationale: Proper documentation of chest tube output is crucial in the care of a patient with a chest tube. While ensuring the chest tube is secured and functioning, checking for air leaks, and maintaining drainage below chest level are important aspects of care, documentation of output is essential for monitoring the patient's condition, assessing the effectiveness of treatment, and ensuring appropriate interventions if needed.
2. Which nursing action will best help a patient with diabetes manage their condition?
- A. Monitor the patient's blood sugar levels regularly.
- B. Encourage the patient to follow a diabetic meal plan.
- C. Teach the patient how to administer insulin.
- D. Teach the patient about the complications of diabetes.
Correct answer: C
Rationale: The correct answer is C: Teach the patient how to administer insulin. This action is crucial in promoting self-management and control of diabetes. By educating the patient on administering insulin, they can actively participate in their treatment plan. Monitoring blood sugar levels (choice A) is important but doesn't empower the patient to take direct action. Encouraging a diabetic meal plan (choice B) is beneficial but may not directly address the need for insulin administration. Teaching about the complications of diabetes (choice D) is essential but may not be as immediately impactful as teaching insulin administration for day-to-day management.
3. A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Suggest that the client use a salt substitute
- B. Obtain a 12-lead ECG
- C. Obtain a blood sample for a serum sodium level
- D. Advise the client to add citrus juices and bananas to their diet
Correct answer: B
Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.
4. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?
- A. Bend at the waist when picking up objects.
- B. Avoid lying on the operative side.
- C. Avoid lifting more than 10 lb.
- D. Apply ice to the affected eye.
Correct answer: C
Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.
5. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?
- A. White blood cell count (WBC)
- B. C-reactive protein (CRP)
- C. Erythrocyte sedimentation rate (ESR)
- D. Hemoglobin and hematocrit levels
Correct answer: A
Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.
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