ATI RN
ATI Capstone Comprehensive Assessment B
1. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?
- A. Donning sterile gown and gloves to remove the wound dressing
- B. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
- C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
- D. Donning clean goggles, gown, and gloves to dress the wound
Correct answer: C
Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.
2. A client with hypertension is prescribed atenolol. Which of the following findings should the nurse include as adverse effects of this medication?
- A. Cough
- B. Tremor
- C. Constipation
- D. Bradycardia
Correct answer: D
Rationale: Correct. Bradycardia is a known adverse effect of atenolol, a beta-blocker medication commonly used to treat hypertension. Atenolol can slow down the heart rate, leading to bradycardia. The nurse should monitor the client for signs of bradycardia, such as dizziness, fatigue, or fainting. Choices A, B, and C are incorrect because cough, tremor, and constipation are not typically associated with atenolol use.
3. 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.
4. When teaching a patient with a new prescription for brimonidine to treat open-angle glaucoma, what indicates an understanding of the instructions?
- A. I can expect my vision to improve quickly
- B. I should use it only when my eyes are irritated
- C. I can expect to feel some irritation when I put these drops in my eyes
- D. I will need regular eye exams
Correct answer: C
Rationale: The correct answer is C. When using brimonidine to treat open-angle glaucoma, patients may experience temporary irritation in the eyes. Choice A is incorrect because vision improvement from brimonidine is not immediate. Choice B is incorrect as brimonidine should be used as prescribed, not just when eyes are irritated. Choice D is important but does not directly indicate an understanding of the medication's use.
5. The client has a do-not-resuscitate (DNR) order. The family asks the nurse to ignore the DNR if the client codes. What is the nurse's responsibility?
- A. Follow the family's wishes
- B. Explain that the DNR must be honored
- C. Ignore the DNR and proceed with CPR
- D. Perform CPR if the client codes
Correct answer: B
Rationale: The correct answer is B: 'Explain that the DNR must be honored.' The nurse's responsibility is to follow the DNR order, as it is a legal and ethical obligation. Choice A is incorrect because following the family's wishes would go against the established DNR order. Choice C is incorrect as ignoring the DNR order is not appropriate. Choice D is also incorrect as performing CPR would be contrary to the client's expressed wishes in the DNR order.
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