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. A healthcare professional is planning care for a client who is scheduled for a lumbar puncture. Which of the following actions should the healthcare professional include?
- A. Restrict the client's fluid intake for 4 hours following the procedure
- B. Apply cold compresses to the puncture site after the procedure
- C. Instruct the client to increase oral fluid intake after the procedure
- D. Keep the client in a prone position for 12 hours after the procedure
Correct answer: C
Rationale: The correct action to include in caring for a client scheduled for a lumbar puncture is to instruct the client to increase oral fluid intake after the procedure. Increasing oral fluid intake helps replace cerebrospinal fluid lost during the lumbar puncture and reduces the risk of headaches. Restricting fluid intake (Choice A) is not recommended as it can lead to dehydration. Applying cold compresses (Choice B) is not necessary after a lumbar puncture. Keeping the client in a prone position for 12 hours (Choice D) is not required after a lumbar puncture and can cause discomfort and complications.
3. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?
- A. Encourage the patient to take deep breaths.
- B. Assist the patient to sit down slowly.
- C. Instruct the patient to use a walker for support.
- D. Teach the patient how to change positions safely.
Correct answer: B
Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.
4. A client with severe dyspnea is scheduled for multiple diagnostic tests. Which test should the nurse prioritize?
- A. Administer an echocardiogram first.
- B. Prioritize a chest x-ray for the client.
- C. Prepare the client for a CT scan.
- D. Order an MRI first.
Correct answer: B
Rationale: The correct answer is B: Prioritize a chest x-ray for the client. When a client presents with severe dyspnea, a chest x-ray should be prioritized as it helps in assessing the lungs and heart, which are crucial in cases of respiratory distress. Echocardiograms are more focused on assessing heart function and may not provide immediate information needed in cases of dyspnea. CT scans and MRIs are more detailed imaging studies that are not typically the first-line diagnostic tests for severe dyspnea.
5. A healthcare professional is giving a change-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is the priority for the healthcare professional to provide?
- A. Recent chest x-ray results
- B. Medication history
- C. Breath sounds
- D. Lab results
Correct answer: C
Rationale: The correct answer is C: 'Breath sounds.' When providing a change-of-shift report for a client with pneumonia, the priority information to communicate is the assessment of breath sounds. Monitoring breath sounds is crucial in assessing respiratory status and the effectiveness of treatments in pneumonia. Option A, recent chest x-ray results, may be important but does not provide real-time information on the client's current status. Option B, medication history, is relevant but not as immediate as assessing breath sounds. Option D, lab results, can provide valuable information but may not be as urgent as monitoring the client's respiratory status through breath sounds.
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