ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. Which intervention is essential when caring for a patient with a nasogastric (NG) tube?
- A. Suction the NG tube every 4 hours.
- B. Check the placement of the NG tube before each feeding.
- C. Flush the NG tube with water before and after each medication administration.
- D. Remove the NG tube once the patient feels comfortable.
Correct answer: B
Rationale: Checking the placement of the NG tube before each feeding is crucial to ensure it is correctly positioned and safe to use. Option A is incorrect as routine suctioning can lead to complications and should only be done as needed. Option C is not necessary unless there are specific instructions for flushing. Option D is incorrect as the NG tube should only be removed by healthcare professionals based on medical criteria, not solely based on the patient's comfort.
2. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?
- A. Confront the nurse about the behavior.
- B. Notify the hospital's safety committee.
- C. Document the observation without addressing it.
- D. Follow up with the nurse at a later time.
Correct answer: B
Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.
3. A healthcare provider writes a prescription for a medication dose three times the normal range. What should the nurse do?
- A. Administer the medication as prescribed
- B. Question the prescription with the provider
- C. Consult with the pharmacist about the dosage
- D. Delay the medication until verification can be made
Correct answer: B
Rationale: The correct action for the nurse in this situation is to question the prescription with the provider. Administering a medication dose three times the normal range without clarification could pose serious risks to the client. Consulting with the pharmacist about the dosage or delaying the medication until verification can be made are not the initial steps to take; the nurse should first clarify the prescription with the healthcare provider to ensure patient safety.
4. When is removal of the restraints by the nurse appropriate?
- A. When medication that has been administered has taken effect
- B. When no acts of aggression are observed in the hour following the release of two extremity restraints
- C. When the nurse explores with the client the reasons for the angry and aggressive behavior
- D. When the client apologizes and tells the nurse that it will never happen again
Correct answer: B
Rationale: The correct answer is B. The nurse can safely remove restraints once no aggressive behavior is observed after releasing two extremity restraints for an hour. Choice A is incorrect because the removal of restraints should be based on the client's behavior rather than just the effect of medication. Choice C is incorrect as exploring reasons for aggressive behavior should be done before or during the intervention, not as a condition for removing restraints. Choice D is incorrect since an apology from the client does not guarantee a change in behavior or indicate that it is safe to remove the restraints.
5. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?
- A. Redness and swelling are normal after surgery
- B. Any drainage from the incision site is not concerning
- C. Yellow drainage is normal
- D. I should monitor for increased redness or warmth
Correct answer: B
Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.
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