ATI RN
ATI Capstone Comprehensive Assessment B
1. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?
- A. Place the call light within the patient's reach.
- B. Apply a yellow fall risk bracelet to the patient.
- C. Assist the patient when ambulating.
- D. Ensure the patient's room is well-lit.
Correct answer: B
Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.
2. A nurse is observing a patient's use of a walker. Which observation indicates a need for further teaching?
- A. The patient advances the walker too far ahead.
- B. The patient uses the walker to assist in standing.
- C. The patient maintains their balance while using the walker.
- D. The patient walks with their back hunched over.
Correct answer: A
Rationale: The correct answer is A because advancing the walker too far ahead increases the risk of falls, indicating a need for further teaching. Choice B is correct as using the walker to assist in standing is a proper use. Choice C is correct as maintaining balance while using the walker shows proper technique. Choice D is incorrect as walking with the back hunched over is a posture issue, not directly related to walker use.
3. What are the key considerations when administering opioid analgesics to a patient in pain?
- A. Monitoring for respiratory depression
- B. Administering opioid antagonist if needed
- C. Assessing respiratory rate and pain level before administration
- D. Monitoring the patient's level of consciousness
Correct answer: A
Rationale: The correct key consideration when administering opioid analgesics to a patient in pain is monitoring for respiratory depression. Opioids can lead to respiratory depression, making it crucial to carefully monitor the patient's breathing. Administering an opioid antagonist is not a key consideration during the administration of opioids; it is used to reverse opioid effects in cases of overdose, not as a routine practice. Assessing respiratory rate and pain level before administration is important but not the key consideration compared to monitoring for respiratory depression. Monitoring the patient's level of consciousness is also essential but not as critical as monitoring for respiratory depression when administering opioids.
4. How should a healthcare provider respond to a patient who is exhibiting signs of acute myocardial infarction (AMI)?
- A. Calling for emergency assistance immediately
- B. Administering nitroglycerin as prescribed
- C. Monitoring the patient's cardiac rhythm
- D. Administering oxygen and preparing for ECG
Correct answer: A
Rationale: When a patient is exhibiting signs of acute myocardial infarction (AMI), the priority action is to call for emergency assistance immediately. This ensures that the patient receives prompt and appropriate care, including interventions such as administering oxygen, nitroglycerin, and monitoring cardiac rhythm. Administering nitroglycerin should only be done if prescribed by a healthcare provider after assessment and confirmation of AMI. Monitoring the patient's cardiac rhythm is important but not the initial action needed in this critical situation. Administering oxygen and preparing for an ECG are important interventions but should follow the immediate step of calling for emergency assistance.
5. A charge nurse on a medical-surgical unit is preparing to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks should the charge nurse delegate to the LPN?
- A. Administering an oral antibiotic to a client
- B. Performing an admission assessment of a client
- C. Creating new teaching for a guardian of a toddler
- D. Administering IV conscious sedation to a client
Correct answer: A
Rationale: Administering oral antibiotics is within the scope of practice for an LPN and can be safely delegated. LPNs are trained to administer medications, including oral ones. Performing an admission assessment (Choice B) involves critical thinking and comprehensive evaluation, typically done by registered nurses. Creating new teaching material (Choice C) requires specialized knowledge and is usually the responsibility of a nurse with additional training in education. Administering IV conscious sedation (Choice D) is a high-risk task that requires advanced skills and should be performed by a registered nurse or higher-level provider.
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