ATI RN
ATI Capstone Comprehensive Assessment B
1. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. I should call 911 if my grandchild loses consciousness.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. If my grandchild eats a plant, I should provide syrup of ipecac.
- D. The number for poison control is 800-222-1222.
Correct answer: C
Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.
2. A client who has a new prescription for ferrous sulfate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect dark tarry stools.
- B. I should expect increased bruising.
- C. I will not get as many infections.
- D. I will expect the color of my urine to be amber.
Correct answer: A
Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.
3. A nurse suspects a colleague of diverting narcotics. What is the nurse's first course of action?
- A. Confront the colleague directly about the suspicion.
- B. Report the suspicion to the nurse manager.
- C. Ignore the situation unless there is clear evidence.
- D. Keep a record of the colleague's actions for future reference.
Correct answer: B
Rationale: The correct first course of action for a nurse suspecting a colleague of diverting narcotics is to report the suspicion to the nurse manager. Confronting the colleague directly may not be safe and could compromise the investigation. Ignoring the situation is not appropriate as it can pose risks to patient safety. Keeping a record of the colleague's actions is not the primary action to take when drug diversion is suspected; reporting to the nurse manager is crucial for proper investigation and ensuring patient safety.
4. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?
- A. Administer a diuretic as prescribed.
- B. Place the patient in a high Fowler's position.
- C. Administer oxygen via nasal cannula.
- D. Monitor the patient's lung sounds every 2 hours.
Correct answer: B
Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.
5. The nurse notes that a healthcare provider has prescribed a higher than normal dose of medication. What action should the nurse take?
- A. Administer the prescribed dose
- B. Ask another nurse to verify the dose
- C. Administer half of the dose
- D. Contact the healthcare provider to clarify the prescription
Correct answer: D
Rationale: When a healthcare provider prescribes a dose that is higher than normal, it is crucial for the nurse to contact the provider to clarify the prescription. Administering the prescribed dose without clarification can lead to potential harm to the patient due to the elevated dosage. Asking another nurse to verify the dose may not provide the necessary clarification from the prescriber. Administering only half of the prescribed dose without consulting the healthcare provider is not the appropriate action, as the full rationale behind the higher dose needs to be understood before any administration.
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