ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?
- A. Positioning the patient in a prone position
- B. Monitoring vital signs and lung sounds
- C. Preparing for mechanical ventilation
- D. Administering supplemental oxygen
Correct answer: A
Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.
2. A nurse is teaching a female client who is experiencing alcohol withdrawal about chlordiazepoxide. Which of the following information should the nurse include in the teaching?
- A. This medication may increase your blood pressure
- B. Breast tenderness may occur with this medication
- C. You can double the dose of medication if you feel anxious
- D. Notify the provider if pregnancy is desired or suspected
Correct answer: D
Rationale: Pregnancy can complicate alcohol withdrawal treatment, and the provider should be notified.
3. A community nurse is instructing a group of newly licensed nurses about diseases that require airborne precautions. Which of the following diseases should the nurse include?
- A. Rubella
- B. Pertussis
- C. Influenza
- D. Varicella
Correct answer: D
Rationale: The correct answer is D, Varicella. Varicella (chickenpox) is a disease that requires airborne precautions to prevent its spread. Airborne precautions are necessary to prevent transmission of pathogens that remain infectious over long distances when suspended in the air. Rubella, pertussis, and influenza do not require airborne precautions. Rubella and pertussis require droplet precautions, while influenza requires droplet and contact precautions. Therefore, Varicella is the only disease in the list that necessitates airborne precautions.
4. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Inject at a 90-degree angle
- B. Inject at a 45-degree angle
- C. Massage the injection site after administering
- D. Use a longer needle
Correct answer: B
Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.
5. A client with diabetes mellitus is prescribed prednisone for a rash. Which statement by the client indicates the need for further teaching?
- A. I might have trouble falling asleep while taking prednisone
- B. I might feel emotional when I am on this medicine
- C. I might need to increase my regular insulin during this time
- D. I will gradually stop the prednisone when my rash goes away
Correct answer: D
Rationale: The correct answer is D. Prednisone should never be stopped abruptly; it must be tapered down. Stopping it suddenly can lead to adrenal insufficiency. Choices A, B, and C are all potential side effects or considerations when taking prednisone and do not indicate a need for further teaching.
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