ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?
- A. Encourage physical activity to reduce withdrawal symptoms
- B. Administer diazepam to prevent seizures
- C. Monitor for signs of dehydration
- D. Encourage the client to verbalize their feelings
Correct answer: B
Rationale: The most appropriate intervention for a client experiencing acute alcohol withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to prevent seizures and manage the symptoms of alcohol withdrawal. Encouraging physical activity may not be safe during acute withdrawal as the client may be at risk for seizures and other complications. Monitoring for signs of dehydration is important but not the most immediate intervention needed in acute alcohol withdrawal. While encouraging the client to verbalize their feelings is beneficial for therapeutic communication, it is not the priority intervention when managing acute alcohol withdrawal.
2. A nurse is teaching a client who has a new prescription for digoxin. Which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?
- A. Increased appetite
- B. Rash on the face
- C. Yellow-tinged vision
- D. Weight gain
Correct answer: C
Rationale: The correct answer is C: 'Yellow-tinged vision.' Yellow-tinged vision is a characteristic sign of digoxin toxicity, indicating an overdose of the medication. This visual disturbance is a critical adverse effect that should be reported promptly to the healthcare provider to prevent serious complications.\n\nChoice A, 'Increased appetite,' is not typically associated with digoxin use and is not a common adverse effect.\n\nChoice B, 'Rash on the face,' is also not a common adverse effect of digoxin. Skin rash is not a typical manifestation of digoxin toxicity.\n\nChoice D, 'Weight gain,' is not a common adverse effect of digoxin. Weight gain is not a typical symptom of digoxin toxicity and is unlikely to be related to the medication.
3. A patient is being taught to use TD nitroglycerin patches to treat angina pectoris. What instructions should be included?
- A. Apply a patch every 12 hours
- B. Apply a new patch every morning
- C. Use it only when symptoms appear
- D. Rotate the application site weekly
Correct answer: B
Rationale: The correct answer is to apply a new patch every morning. Nitroglycerin patches should be applied in the morning and removed at bedtime to provide a 14-hour nitrate-free interval, preventing tolerance development. Choice A is incorrect because applying a patch every 12 hours may lead to tolerance. Choice C is incorrect because nitroglycerin patches are used prophylactically, not just when symptoms appear. Choice D is incorrect because rotating the application site weekly is not necessary; the same site can be used as long as there is no skin irritation.
4. A female client with anxiety disorder is being taught about alprazolam by a nurse. Which of the following information should the nurse include in the teaching?
- A. This medication may increase your blood pressure
- B. Use a reliable form of contraception while taking this medication
- C. If a dose is missed, double the next dose of medication
- D. Do not eat aged cheeses while taking this medication
Correct answer: B
Rationale: The correct answer is B. Alprazolam can increase the risk of pregnancy complications, so using a reliable form of contraception is essential to prevent unintended pregnancies. Choice A is incorrect because alprazolam typically does not increase blood pressure. Choice C is incorrect as doubling the next dose after a missed dose can lead to overdose and adverse effects. Choice D is unrelated to alprazolam and is not a concern when taking this medication.
5. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
- A. Check for orthostatic hypotension
- B. Use a gait belt
- C. Position the chair on the strong side
- D. Ask for assistance
Correct answer: A
Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.
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