ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?
- A. Provide cognitive-behavioral therapy
- B. Offer frequent orientation and reassurance
- C. Administer a sedative to improve memory recall
- D. Refer the client to a neurologist for further evaluation
Correct answer: B
Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.
2. A nurse at a local health department is caring for a client who is newly diagnosed with listeriosis. Which of the following actions should the nurse plan to take?
- A. Provide the Centers for Disease Control (CDC) and Prevention with the client's information
- B. Inform the client that they are required to have health department staff directly observe their treatment
- C. Determine whether the condition is reportable under state requirements
- D. Find out whether the condition is endemic in the client's neighborhood
Correct answer: C
Rationale: The correct answer is C: 'Determine whether the condition is reportable under state requirements.' Listeriosis is a reportable disease, meaning healthcare providers are legally required to report cases to public health authorities. By checking the state requirements for reportable diseases, the nurse ensures compliance with public health regulations. Choice A is incorrect because providing the client's information to the CDC is not the immediate action needed. Choice B is incorrect as direct observation of treatment is not a standard procedure for listeriosis. Choice D is also incorrect as determining if the condition is endemic in the client's neighborhood is not the primary concern when managing a diagnosed case of listeriosis.
3. What is the most important action for the nurse to take before administering digoxin to a patient?
- A. Check the patient's heart rate before administration.
- B. Assess the patient's blood pressure before administration.
- C. Ensure the patient has eaten before administration.
- D. Monitor the patient's weight before administration.
Correct answer: A
Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.
4. If a nurse is uncomfortable documenting a verbal prescription, what should the nurse do?
- A. Document the prescription without seeking clarification.
- B. Clarify the verbal prescription with the healthcare provider.
- C. Refuse to document the prescription.
- D. Speak with the client's family to clarify the situation.
Correct answer: B
Rationale: When a nurse is uncomfortable documenting a verbal prescription, the best course of action is to clarify the prescription with the healthcare provider. This is crucial to ensure that the information is accurate and to provide safe and appropriate care. Option A is incorrect because blindly documenting without seeking clarification can lead to errors. Option C is incorrect as refusing to document the prescription altogether is not in the best interest of the patient. Option D is also incorrect as speaking with the client's family is not the appropriate step to clarify a verbal prescription; the healthcare provider should be the primary source for this clarification.
5. A client has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?
- A. Lemon sherbet
- B. Milkshake
- C. Vanilla ice cream
- D. Grape juice
Correct answer: D
Rationale: Grape juice is the correct choice for a clear liquid diet because it is a liquid that is transparent and does not contain any solid particles. Lemon sherbet, milkshake, and vanilla ice cream are not appropriate for a clear liquid diet as they all contain solid particles or are not in liquid form.
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