ATI RN
ATI Capstone Comprehensive Assessment B
1. What should be done to ensure safety during the transfer of a patient with limited mobility?
- A. Have the patient use a gait belt for support.
- B. Encourage the patient to hold onto a walker.
- C. Lock the wheels on the bed and wheelchair.
- D. Ask the patient to transfer independently.
Correct answer: C
Rationale: The correct answer is to lock the wheels on the bed and wheelchair. This action helps prevent accidents by stabilizing the equipment during the transfer process. Having the patient use a gait belt for support (choice A) can be helpful but is not directly related to equipment safety. Encouraging the patient to hold onto a walker (choice B) is beneficial for ambulation but does not address the safety of equipment. Asking the patient to transfer independently (choice D) can pose risks, especially for a patient with limited mobility, and may not ensure safety during the transfer.
2. How is the effectiveness of a diuretic in a patient with heart failure evaluated?
- A. Checking daily weights and lung sounds for improvement
- B. Assessing the patient's blood pressure and urine output
- C. Monitoring for weight loss and reduction in edema
- D. Measuring the patient's heart rate and lung sounds
Correct answer: A
Rationale: The correct way to evaluate the effectiveness of a diuretic in a patient with heart failure is by checking daily weights and lung sounds for improvement. Daily weights help to assess fluid retention changes, while improvement in lung sounds indicates reduced pulmonary congestion. Assessing blood pressure and urine output (Choice B) is important but does not directly evaluate the effectiveness of the diuretic. Monitoring for weight loss and reduction in edema (Choice C) are valid indicators of diuretic effectiveness, but direct observation of daily weights and lung sounds is more specific. Measuring heart rate and lung sounds (Choice D) is relevant but does not directly assess the impact of the diuretic on fluid balance and pulmonary status.
3. A nurse witnesses a colleague administering the wrong IV solution to a client. What should the nurse do first?
- A. Complete an incident report.
- B. Ask the colleague if they intend to report the error.
- C. Call the healthcare provider to notify them of the error.
- D. Notify the supervisor about the situation.
Correct answer: B
Rationale: The correct first step for the nurse to take in this situation is to ask the colleague if they intend to report the error. It is important to address the error promptly and directly with the colleague involved to ensure that the appropriate actions are taken to correct the mistake and prevent harm to the client. Completing an incident report, calling the healthcare provider, or notifying the supervisor can be done after discussing the error with the colleague. Immediate communication with the colleague directly involved in the error is crucial to address the situation effectively.
4. A patient has a new prescription for allopurinol to treat gout. What should the nurse include in the teaching?
- A. Decrease protein intake
- B. Limit salt intake
- C. Increase fluid intake
- D. Limit alcohol
Correct answer: C
Rationale: Correct answer: Increasing fluid intake is essential when taking allopurinol to prevent kidney stones and aid in uric acid excretion. This helps reduce the risk of developing complications associated with gout. Decreasing protein intake (Choice A) is not directly related to allopurinol therapy. Limiting salt intake (Choice B) and alcohol consumption (Choice D) are important for overall health but are not specific recommendations when taking allopurinol for gout.
5. What is the priority action when a patient is experiencing an allergic reaction to a medication?
- A. Monitor the patient's blood pressure every 15 minutes.
- B. Discontinue the medication and notify the healthcare provider.
- C. Administer an antihistamine to reduce symptoms.
- D. Monitor the patient's urine output closely.
Correct answer: B
Rationale: The correct answer is to discontinue the medication and notify the healthcare provider when a patient is experiencing an allergic reaction to a medication. This action is crucial to prevent further harm to the patient. Monitoring blood pressure (choice A) or urine output (choice D) may be important but is not the priority when managing an allergic reaction. Administering an antihistamine (choice C) should only be done after discontinuing the medication and consulting with the healthcare provider.
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