ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. How should a healthcare provider manage a patient with deep vein thrombosis (DVT)?
- A. Monitoring for signs of pulmonary embolism
- B. Applying compression stockings
- C. Administering anticoagulants as prescribed
- D. Encouraging leg elevation to reduce swelling
Correct answer: A
Rationale: Corrected Rationale: Monitoring for signs of pulmonary embolism is crucial in patients with deep vein thrombosis (DVT) as it can be a life-threatening complication. While administering anticoagulants as prescribed is important for preventing clot progression, the immediate concern is detecting potential pulmonary embolism. Applying compression stockings and encouraging leg elevation are beneficial measures for managing DVT symptoms but are not as critical as monitoring for pulmonary embolism.
2. A nurse manager notices a discrepancy in a nurse's narcotics record. What is the appropriate action?
- A. Ask the nurse for clarification about the record.
- B. Report the discrepancy to the pharmacy.
- C. Report the issue to the nurse manager immediately.
- D. Ignore the discrepancy as a clerical error.
Correct answer: B
Rationale: The appropriate action when a nurse manager notices a discrepancy in a nurse's narcotics record is to report the discrepancy to the pharmacy. Reporting such discrepancies is crucial to ensure accountability and patient safety. Choice A is incorrect because the nurse manager should not confront the nurse directly without proper investigation. Choice C is incorrect because reporting to the nurse manager may not address the issue effectively. Choice D is incorrect because ignoring the discrepancy can compromise patient safety and violates protocols.
3. What is the most important nursing intervention when caring for a patient with a wound?
- A. Apply an occlusive dressing over the wound.
- B. Clean the wound with normal saline.
- C. Administer antibiotics as prescribed.
- D. Reassess the wound every 4 hours for changes.
Correct answer: B
Rationale: The most important nursing intervention when caring for a patient with a wound is to clean the wound with normal saline. This is crucial for preventing infection and promoting healing. Applying an occlusive dressing (Choice A) can be important but should come after cleaning the wound. Administering antibiotics (Choice C) is not the first-line intervention for all wounds and should be based on the healthcare provider's prescription. Reassessing the wound (Choice D) is essential but not the most important initial intervention.
4. A nurse is preparing to administer a high dose of morphine to a patient with terminal cancer. What is the nurse's primary consideration before administration?
- A. Ensure the family is aware of the dosage to be administered.
- B. Monitor the patient for respiratory depression.
- C. Administer the morphine in divided doses.
- D. Delay administration until the next assessment.
Correct answer: B
Rationale: The correct answer is B: Monitor the patient for respiratory depression. When administering a high dose of morphine, the nurse's primary consideration should be to monitor the patient for respiratory depression, as morphine can slow down breathing, especially in higher doses. Option A is incorrect because the primary focus should be on the patient's well-being and safety rather than family awareness at this point. Option C is not the best approach as the immediate concern is monitoring the patient closely for any adverse effects. Option D is not advisable as delaying administration without a valid reason can compromise pain management in a terminal cancer patient.
5. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?
- A. Ensure the client is on seizure precautions.
- B. Educate the client about seizure triggers.
- C. Monitor for signs of an impending seizure.
- D. Initiate IV access for anti-seizure medication.
Correct answer: A
Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.
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