ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. How should a healthcare professional position a patient to reduce the risk of pressure ulcers?
- A. Position the patient in the supine position for long periods.
- B. Use pillows to support bony prominences.
- C. Turn the patient every 4 hours.
- D. Place the patient on an alternating pressure mattress.
Correct answer: B
Rationale: Correctly positioning a patient to reduce the risk of pressure ulcers involves using pillows to support bony prominences. This helps to relieve pressure from vulnerable areas and prevent the development of pressure ulcers. Choice A is incorrect because keeping a patient in the supine position for extended periods can increase the risk of pressure ulcers. Choice C is incorrect as turning the patient every 2 hours, rather than every 4 hours, is recommended to prevent pressure ulcers. Choice D is not the best option mentioned for positioning a patient to reduce pressure ulcer risk; although alternating pressure mattresses can be beneficial, using pillows for support is a more direct and commonly used method.
2. What is an appropriate parenting technique for time-out disciplining in children with mental health issues?
- A. Provide positive reinforcement for minor infractions
- B. Remove all privileges for at least one week following a violation
- C. Limit the child's time outside of the home environment
- D. Time-out should only be used in severe situations
Correct answer: B
Rationale: The correct answer is B: 'Remove all privileges for at least one week following a violation.' When dealing with children with mental health issues, it is essential to have consistent consequences for their actions. Providing positive reinforcement for minor infractions (choice A) may not effectively address inappropriate behaviors that require disciplinary action. Limiting the child's time outside the home environment (choice C) does not directly address the behavioral issue. Using time-out only in severe situations (choice D) may not provide consistent consequences for the child's behavior and can lead to escalation before interventions are used.
3. What is the most appropriate method for assessing a patient's pain level?
- A. Observe the patient's facial expressions.
- B. Use a standardized pain scale, such as 0-10.
- C. Ask the patient to rate their pain based on their mood.
- D. Ask the patient's family members to assess the pain.
Correct answer: B
Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.
4. Which intervention is most effective for managing a patient with constipation?
- A. Increase the patient's fluid intake.
- B. Administer a stool softener as prescribed.
- C. Provide the patient with a high-fiber diet.
- D. Teach the patient to perform Valsalva maneuvers.
Correct answer: B
Rationale: The most effective intervention for managing constipation in a patient is to administer a stool softener as prescribed. Stool softeners help relieve constipation by making the stool easier to pass, especially in postoperative patients. Increasing fluid intake can be beneficial but may not address the underlying cause of constipation. While a high-fiber diet is important for bowel health, it may not provide immediate relief for constipation. Teaching a patient to perform Valsalva maneuvers is not recommended for managing constipation as it can lead to adverse effects like increasing intra-abdominal pressure.
5. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?
- A. Uses a sterile bottled solution more than once within a 24-hour period.
- B. Uses surgical aseptic technique to suction an airway.
- C. Uses a clean technique for inserting a urinary catheter.
- D. Uses a cleaning stroke from the urinary meatus toward the rectum.
Correct answer: C
Rationale: The correct answer is C. Using a clean technique for inserting a urinary catheter increases the risk for healthcare-associated infections. Invasive procedures like catheter insertion require a sterile technique to prevent introducing pathogens into the urinary tract. Choices A and B demonstrate appropriate infection control measures by emphasizing the use of sterile or aseptic techniques. Choice D represents an incorrect technique that can lead to the introduction of bacteria from the rectum into the urinary tract, potentially causing infections.
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