ATI RN
ATI Capstone Comprehensive Assessment B
1. What is the recommended procedure for a healthcare professional to follow when applying sterile gloves?
- A. Use non-sterile gloves first, followed by sterile gloves.
- B. Put on sterile gloves, then gown.
- C. Apply gloves after donning a mask.
- D. Apply gloves before touching any sterile equipment.
Correct answer: D
Rationale: The correct procedure for applying sterile gloves is to do so before touching any sterile equipment or surfaces. This helps maintain the sterility of the gloves. Choices A, B, and C are incorrect because they suggest incorrect sequences that may compromise the sterility of the gloves. Using non-sterile gloves first can introduce contamination, putting on gloves before a gown can lead to contamination of the gloves during gowning, and applying gloves after donning a mask can risk contamination of the gloves from the mask.
2. A nurse is caring for a client following an esophagogastroduodenoscopy (EGD). Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Pain
- C. Nausea
- D. Gag reflex
Correct answer: D
Rationale: The correct answer is assessing the gag reflex. This is the priority assessment following an EGD procedure to prevent aspiration. Checking the gag reflex helps ensure the client's airway protection. Assessing the level of consciousness is important, but ensuring the client can protect their airway takes precedence. Pain and nausea assessments are also essential but are secondary to maintaining airway patency.
3. While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?
- A. Blood pressure
- B. Heart rate
- C. Respiratory rate
- D. Temperature
Correct answer: C
Rationale: The correct answer is monitoring the respiratory rate. Morphine can depress respiratory function, leading to respiratory depression or arrest. Therefore, closely monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress. While blood pressure, heart rate, and temperature are important assessments, in this scenario, respiratory rate takes precedence due to the potential respiratory complications associated with morphine administration.
4. A nurse is discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?
- A. To donate organs, a client must provide consent prior to death
- B. The transplant team will harvest the organs for donation from the donor client
- C. During admission, all clients over the age of 18 should be asked about their organ donor status
- D. The National Organ Transplant Act prohibits the sale and purchase of organs
Correct answer: C
Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.
5. What are the clinical manifestations of left-sided heart failure, and how do they differ from right-sided heart failure?
- A. Jugular venous distention and hepatojugular reflex
- B. Hepatomegaly, ascites, and peripheral edema
- C. Dyspnea, cough, and orthopnea
- D. Pulmonary congestion and fatigue
Correct answer: A
Rationale: The correct answer is A. Clinical manifestations of left-sided heart failure include pulmonary symptoms such as dyspnea, cough, and orthopnea. However, left-sided heart failure can also manifest as jugular venous distention and hepatojugular reflex due to the backflow of blood into the pulmonary circulation. Right-sided heart failure is characterized by systemic symptoms like hepatomegaly, ascites, and peripheral edema. Choice B is incorrect as it presents manifestations of right-sided heart failure. Choice C includes symptoms of left-sided heart failure. Choice D describes pulmonary congestion, which is more specific to left-sided heart failure, but it does not encompass the full range of clinical manifestations for left-sided heart failure.
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