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 client with a DNR order has requested resuscitation during a visit from the family. What is the nurse's best course of action?
- A. Follow the family's request and perform CPR.
- B. Explain to the family that the DNR must be honored.
- C. Call the healthcare provider to cancel the DNR order.
- D. Delay resuscitation until further clarification can be made.
Correct answer: B
Rationale: The correct course of action for the nurse is to explain to the family that the DNR (Do Not Resuscitate) order must be honored. It is essential for the nurse to uphold the client's wishes as documented in the DNR order. Performing CPR against the client's expressed wishes in the DNR order would violate ethical and legal standards. Calling the healthcare provider to cancel the DNR order without the client's consent is inappropriate and goes against the client's autonomy. Delaying resuscitation can be detrimental in an emergency situation and may not align with the client's wishes as outlined in the DNR order.
3. A healthcare professional is reviewing the medical record of a client who received their medications 1 hour ago. The client reports chest pain. This can be an adverse effect of what medication?
- A. Digoxin
- B. Albuterol
- C. Lisinopril
- D. Metoprolol
Correct answer: B
Rationale: The correct answer is B, Albuterol. Albuterol can cause chest pain as a side effect due to its beta-agonist effects, which can lead to chest discomfort. Digoxin (choice A) is not typically associated with causing chest pain. Lisinopril (choice C) and Metoprolol (choice D) are not known to commonly cause chest pain as a side effect.
4. A healthcare professional is reviewing the notes written by a previous shift. Which documentation reflects proper guidelines?
- A. Incomplete entries are acceptable as long as they are justified
- B. Documentation should include objective observations only
- C. Corrections in documentation should be signed and dated
- D. Entries should be modified by another healthcare professional if necessary
Correct answer: B
Rationale: The correct answer is B. Proper documentation should include objective observations and detailed notes to ensure continuity of care. Choice A is incorrect because incomplete entries can lead to gaps in information and compromise patient care. Choice C is not completely accurate as corrections should be made in a manner that does not obscure the original entry but does not necessarily require a signature. Choice D is incorrect as entries should ideally be corrected by the original author to maintain accountability and accuracy.
5. A nurse at a provider's office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (SATA)
- A. Top fruits with yogurt
- B. Add cream to soups
- C. Increase fluids during meals
- D. Use milk instead of water in recipes
Correct answer: A
Rationale: Topping fruits with yogurt is the correct recommendation to increase calorie and protein intake for a client on chemotherapy who is losing weight. Yogurt is a good source of protein and adding it to fruits can provide additional calories as well. Choice B, adding cream to soups, may increase calorie intake but does not specifically address protein needs. Choice C, increasing fluids during meals, is important for hydration but does not directly address calorie and protein intake. Choice D, using milk instead of water in recipes, may increase calorie content but does not focus on increasing protein intake, which is essential for clients on chemotherapy.
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