ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. What are the complications of diabetes mellitus that a nurse should monitor for?
- A. Peripheral neuropathy and retinopathy
- B. All of the above
- C. Diabetic ketoacidosis and hyperosmolar hyperglycemic state
- D. Nephropathy and cardiovascular disease
Correct answer: D
Rationale: The correct answer is D. Complications of diabetes mellitus that a nurse should monitor for include nephropathy and cardiovascular disease, in addition to diabetic ketoacidosis, hyperosmolar hyperglycemic state, neuropathy, and retinopathy. While choices A and C mention some complications of diabetes, they do not cover all the complications that a nurse should monitor for. Choice B is incorrect as it suggests selecting all options, which is not accurate.
2. Which nursing action will best promote patient safety when administering medications?
- A. Check the patient's wristband before administering medications.
- B. Confirm the patient's allergies prior to administration.
- C. Document the medications immediately after administration.
- D. Prepare medications at the medication cart to minimize distractions.
Correct answer: B
Rationale: Confirming the patient's allergies before administering medications is crucial for patient safety as it helps prevent adverse reactions. Checking the patient's wristband is important for identification but may not directly impact medication safety. Documenting medications after administration is necessary but does not primarily promote safety during administration. Preparing medications at the medication cart, rather than the nurse's station, is preferred to ensure accuracy and proper medication handling, but it is not directly related to confirming allergies for safety.
3. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?
- A. Report any sign of infection to the provider immediately
- B. Expect your blood pressure to increase
- C. Easy bruising may occur while taking this medication
- D. Muscle rigidity is an expected adverse effect during the first few days of therapy
Correct answer: A
Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.
4. A client is undergoing chemotherapy and expresses concern about hair loss. What is the best response?
- A. Reassure the client that hair loss is not permanent.
- B. Provide resources for wigs or hairpieces.
- C. Encourage the client to cut their hair short in advance.
- D. Advise the client that chemotherapy causes temporary hair loss.
Correct answer: D
Rationale: The best response when a client undergoing chemotherapy expresses concern about hair loss is to advise them that chemotherapy causes temporary hair loss. This response provides accurate information to the client about the side effect they are experiencing. Choice A is incorrect because it may provide false reassurance as for some individuals, hair loss can be a challenging experience. Choice B is not the best initial response as addressing the client's concerns and providing information should come first. Choice C is not the most appropriate response as cutting hair short may not necessarily prevent hair loss and does not address the client's concerns about the temporary nature of chemotherapy-induced hair loss.
5. Which patient should the nurse see first?
- A. A 1-month-old infant looking at a shiny, round battery just out of arm's reach.
- B. A 56-year-old patient with oxygen and a lighter on the bedside table.
- C. A 56-year-old patient with oxygen using an electric razor for grooming.
- D. A bedridden patient who has a reddened area on the buttocks and needs to be turned.
Correct answer: B
Rationale: The correct answer is B because the patient with oxygen and a lighter on the bedside table is at immediate risk of fire. Oxygen promotes combustion, and having a lighter nearby poses a serious safety hazard. This situation requires urgent attention to prevent a potential disaster. Choices A, C, and D do not present immediate life-threatening risks compared to the patient with oxygen and a lighter nearby.
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