ATI RN
ATI Capstone Comprehensive Assessment B
1. The healthcare provider is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate?
- A. What activities, if any, has your pain prevented you from doing?
- B. When does your pain medication typically take effect on your pain?
- C. Would you please rate your pain on a scale from 0 to 10 for me?
- D. Have you considered working with a physical therapist?
Correct answer: A
Rationale: The most appropriate assessment question in this scenario is asking the patient, 'What activities, if any, has your pain prevented you from doing?' This question helps the healthcare provider understand how pain is impacting the patient's daily activities and mobility, providing valuable insight into the limitations caused by the pain. Choice B focuses on pain medication effectiveness, which is not directly related to mobility assessment. Choice C aims at pain intensity assessment but does not directly address mobility issues. Choice D suggests a solution rather than gathering information about the current impact of pain on mobility.
2. A nurse sees another nurse administering medication without using alcohol swabs. What is the first action the nurse should take?
- A. Ignore the situation to maintain a good working relationship.
- B. Report the behavior to the nurse manager.
- C. Ask the colleague to be more careful next time.
- D. Report the issue after speaking to other colleagues.
Correct answer: B
Rationale: The correct action for the nurse to take when witnessing unsafe medication administration practices, such as not using alcohol swabs, is to report the behavior to the nurse manager immediately. Patient safety is the top priority, and any actions that compromise it must be addressed promptly. Ignoring the situation (Choice A) is not appropriate as it puts patients at risk. Asking the colleague to be more careful (Choice C) may not be effective in ensuring immediate correction of the unsafe practice. Reporting the issue after speaking to other colleagues (Choice D) delays necessary action and may compromise patient safety further.
3. 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.
4. A patient with COPD is admitted with shortness of breath and a productive cough. Which of the following interventions should the nurse implement first?
- A. Administer oxygen at 4 L/min via nasal cannula
- B. Encourage the patient to cough and deep breathe
- C. Place the patient in a high-Fowler’s position
- D. Administer a bronchodilator as prescribed
Correct answer: C
Rationale: Placing the patient in a high-Fowler’s position should be implemented first. This intervention helps improve lung expansion, making it easier for the patient to breathe. Elevating the head of the bed reduces the work of breathing and can alleviate symptoms of respiratory distress. Administering oxygen, encouraging coughing and deep breathing, and administering a bronchodilator are important interventions in the care of a patient with COPD, but positioning the patient for optimal lung expansion takes precedence in this scenario.
5. A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?
- A. Wipe the area around the needleless port with sterile water
- B. Insert the syringe into the needleless port at a 60-degree angle
- C. Withdraw 3 to 5 ml of urine from the port
- D. Don sterile gloves
Correct answer: C
Rationale: The correct action for the nurse to take is to withdraw 3 to 5 ml of urine from the port for an accurate culture and sensitivity test. Wiping the area around the needleless port with sterile water (Choice A) is not necessary when obtaining a urine specimen. Inserting the syringe into the needleless port at a 60-degree angle (Choice B) is incorrect as it does not align with the correct procedure for obtaining a urine specimen. Donning sterile gloves (Choice D) is a good practice but not the immediate action required for obtaining a urine specimen.
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