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. A nurse is assigned to care for four clients. Which client should the nurse assess first?
- A. A client with chest pain and shortness of breath
- B. A client with a fever of 100°F
- C. A client scheduled for surgery
- D. A client with stable vital signs
Correct answer: A
Rationale: The correct answer is A. Chest pain and shortness of breath are symptoms that could indicate a life-threatening condition such as a heart attack or pulmonary embolism. Therefore, this client should be assessed first to ensure prompt intervention and treatment. Choice B, a client with a fever of 100°F, may indicate an infection but is not immediately life-threatening compared to the symptoms of chest pain and shortness of breath. Choice C, a client scheduled for surgery, is not an immediate priority unless there are specific preoperative assessments or interventions required. Choice D, a client with stable vital signs, does not indicate an urgent need for assessment compared to the client with chest pain and shortness of breath.
3. A patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain?
- A. Meditation alters the chemical composition of pain neuroregulators, which closes the gate.
- B. Meditation stops the occurrence of pain stimuli.
- C. Meditation controls pain by blocking pain impulses from coming through the gate.
- D. Meditation will help me sleep through the pain because it opens the gate.
Correct answer: C
Rationale: The correct answer is C. According to the gate control theory, meditation helps relieve pain by blocking pain impulses from coming through the gate in the central nervous system. Choice A is incorrect as meditation does not directly alter the chemical composition of pain neuroregulators. Choice B is incorrect because meditation does not stop the occurrence of pain stimuli. Choice D is incorrect as meditation does not open the gate but rather closes it to block pain impulses.
4. A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?
- A. Sit the client upright
- B. Stop the TPN infusion
- C. Turn the client on their left side
- D. Prepare to add insulin to the TPN infusion
Correct answer: B
Rationale: The correct action for the nurse to take when finding that the TPN solution is infusing too rapidly is to stop the TPN infusion. This is crucial to prevent fluid overload and ensure the client's safety. Sitting the client upright (Choice A) or turning the client on their left side (Choice C) are not appropriate responses to a rapidly infusing TPN solution and do not address the immediate issue of preventing complications from the rapid infusion. Adding insulin to the TPN infusion (Choice D) is not indicated unless specifically prescribed by the healthcare provider for the client's condition. Therefore, the priority action is to stop the TPN infusion to prevent potential harm.
5. Which nursing action will best help a patient with diabetes manage their condition?
- A. Monitor the patient's blood sugar levels regularly.
- B. Encourage the patient to follow a diabetic meal plan.
- C. Teach the patient how to administer insulin.
- D. Teach the patient about the complications of diabetes.
Correct answer: C
Rationale: The correct answer is C: Teach the patient how to administer insulin. This action is crucial in promoting self-management and control of diabetes. By educating the patient on administering insulin, they can actively participate in their treatment plan. Monitoring blood sugar levels (choice A) is important but doesn't empower the patient to take direct action. Encouraging a diabetic meal plan (choice B) is beneficial but may not directly address the need for insulin administration. Teaching about the complications of diabetes (choice D) is essential but may not be as immediately impactful as teaching insulin administration for day-to-day management.
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