ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. What are the common side effects of opioid analgesics, and how should they be managed?
- A. Drowsiness and dizziness, ensuring safety precautions
- B. Respiratory depression, ensuring adequate ventilation
- C. Constipation and nausea, managed with stool softeners
- D. Nausea and vomiting, managing with antiemetics
Correct answer: A
Rationale: The correct answer is A. Common side effects of opioid analgesics include drowsiness and dizziness. These side effects can impair a person's ability to operate machinery or drive safely. To manage these side effects, it is essential to advise patients to avoid activities that require alertness until they know how the medication affects them. Choices B, C, and D are incorrect because respiratory depression, constipation, and nausea are also common side effects of opioids, but they are not the primary side effects being asked for in this question.
2. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?
- A. Change IV solution bags every 36 hr.
- B. Avoid the delegation of hygiene care to assistive personnel (AP)
- C. Wear sterile gloves when removing urinary retention catheters.
- D. Educate staff about the correct use of personal protective equipment (PPE) for isolation precautions
Correct answer: D
Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.
3. A nurse is caring for a client who had a total thyroidectomy and has a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?
- A. Shortened QT intervals
- B. Hypoactive deep tendon reflexes
- C. Tingling of the extremities
- D. Constipation
Correct answer: C
Rationale: The correct answer is C: Tingling of the extremities. Tingling is a common symptom of hypocalcemia, which is expected with low calcium levels after a thyroidectomy. Option A, shortened QT intervals, is associated with hypercalcemia rather than hypocalcemia. Option B, hypoactive deep tendon reflexes, is not typically related to hypocalcemia. Option D, constipation, is not a common finding associated with low calcium levels.
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. When the nurse discovers a patient on the floor, and the patient states, 'I fell out of bed,' the nurse assesses the patient and then places the patient back in bed. What action should the nurse take next?
- A. Re-assess the patient.
- B. Complete an incident report.
- C. Notify the healthcare provider.
- D. Do nothing, as no harm has occurred.
Correct answer: C
Rationale: After a patient has fallen, it is crucial to notify the healthcare provider. The provider needs to be informed so that further assessment, evaluation, or intervention can be carried out to ensure the patient's safety and well-being. Re-assessing the patient (Choice A) is important but notifying the healthcare provider takes precedence. Completing an incident report (Choice B) is necessary but should follow notifying the healthcare provider. Doing nothing (Choice D) is not appropriate as patient safety and potential underlying issues need to be addressed promptly.
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