ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. What is the most important action for the nurse to take after finding a patient on the floor who reports, 'I fell out of bed'?
- A. Reassess the patient.
- B. Complete an incident report.
- C. Notify the health care provider.
- D. Take no action, as no harm has occurred.
Correct answer: C
Rationale: The most important action for the nurse to take after finding a patient on the floor who reports falling out of bed is to notify the health care provider. This is crucial to ensure that the incident is reported, documented, and that the patient receives necessary follow-up care. Reassessing the patient is important, but notifying the healthcare provider takes precedence to address any potential injuries or issues that may have resulted from the fall. Completing an incident report is necessary, but immediate notification to the healthcare provider is more critical in this situation. Doing nothing is not an appropriate response, as the patient's safety and well-being must be the top priority.
2. Which patient should the nurse see first?
- A. A 1-month-old infant looking at a shiny, round battery just out of arm's reach.
- B. A 56-year-old patient with oxygen and a lighter on the bedside table.
- C. A 56-year-old patient with oxygen using an electric razor for grooming.
- D. A bedridden patient who has a reddened area on the buttocks and needs to be turned.
Correct answer: B
Rationale: The correct answer is B because the patient with oxygen and a lighter on the bedside table is at immediate risk of fire. Oxygen promotes combustion, and having a lighter nearby poses a serious safety hazard. This situation requires urgent attention to prevent a potential disaster. Choices A, C, and D do not present immediate life-threatening risks compared to the patient with oxygen and a lighter nearby.
3. A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?
- A. Discuss whether family members will assist with postoperative care
- B. Review the client's current home environment
- C. Identify the client's usual coping mechanisms
- D. Determine what the client knows about the surgery
Correct answer: D
Rationale: In the preoperative phase, determining what the client knows about the surgery is the priority. This action helps address misconceptions, provide necessary information, and ensure the client's understanding and cooperation. Choices A, B, and C are important aspects of preoperative care but assessing the client's knowledge about the surgery takes precedence to alleviate fears, enhance communication, and optimize outcomes.
4. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?
- A. Donning sterile gown and gloves to remove the wound dressing
- B. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
- C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
- D. Donning clean goggles, gown, and gloves to dress the wound
Correct answer: C
Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.
5. A nurse is caring for a client with a new colostomy. What is the nurse's responsibility regarding stoma care?
- A. Educate the client on how to care for the stoma independently.
- B. Contact the stoma nurse to assist the client with care.
- C. Delegate the care of the stoma to a nursing assistant.
- D. Wait until the next shift to address the stoma care.
Correct answer: B
Rationale: The correct answer is to contact the stoma nurse to assist the client with care. Stoma nurses are specially trained to provide guidance on stoma care, especially for clients with new ostomies. Instructing the client to care for the stoma independently (Choice A) may not be appropriate initially as they may need professional guidance. Delegating the care of the stoma to a nursing assistant (Choice C) is not recommended as specialized care is required. Waiting until the next shift (Choice D) is not ideal as stoma care should not be delayed.
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