ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. Which intervention is most effective for managing a patient with constipation?
- A. Increase the patient's fluid intake.
- B. Administer a stool softener as prescribed.
- C. Provide the patient with a high-fiber diet.
- D. Teach the patient to perform Valsalva maneuvers.
Correct answer: B
Rationale: The most effective intervention for managing constipation in a patient is to administer a stool softener as prescribed. Stool softeners help relieve constipation by making the stool easier to pass, especially in postoperative patients. Increasing fluid intake can be beneficial but may not address the underlying cause of constipation. While a high-fiber diet is important for bowel health, it may not provide immediate relief for constipation. Teaching a patient to perform Valsalva maneuvers is not recommended for managing constipation as it can lead to adverse effects like increasing intra-abdominal pressure.
2. A nurse at a provider's office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (SATA)
- A. Top fruits with yogurt
- B. Add cream to soups
- C. Increase fluids during meals
- D. Use milk instead of water in recipes
Correct answer: A
Rationale: Topping fruits with yogurt is the correct recommendation to increase calorie and protein intake for a client on chemotherapy who is losing weight. Yogurt is a good source of protein and adding it to fruits can provide additional calories as well. Choice B, adding cream to soups, may increase calorie intake but does not specifically address protein needs. Choice C, increasing fluids during meals, is important for hydration but does not directly address calorie and protein intake. Choice D, using milk instead of water in recipes, may increase calorie content but does not focus on increasing protein intake, which is essential for clients on chemotherapy.
3. A client asks about becoming an organ donor. What information should the nurse provide?
- A. The process should be discussed with family first.
- B. The organ donation process should begin immediately.
- C. Organ donation can proceed even if the family disagrees.
- D. Donor cards must be signed in the presence of a witness.
Correct answer: D
Rationale: The correct answer is D. For organ donation to be legally valid, the donor must sign consent documents in the presence of a witness. Choice A is incorrect because while discussing with family is important, it is not a legal requirement for organ donation. Choice B is incorrect as the organ donation process involves various steps and procedures that cannot begin immediately. Choice C is incorrect because organ donation typically requires consent and cooperation from the family if the donor is unable to provide consent.
4. A client has bilateral eye patches following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
- A. Explain to the client that their tray is here and place their hands on it
- B. Ask the client if they would prefer a liquid diet
- C. Assign an assistive personnel to feed the client
- D. Describe to the client the location of the food on the tray
Correct answer: D
Rationale: Describing the location of food on the tray helps promote independence for the client with bilateral eye patches. By providing clear instructions on where the food is placed, the client can independently locate and consume their meal. Option A is incorrect as physically placing the client's hands on the tray does not encourage independence. Option B is unnecessary unless there are specific dietary restrictions indicated. Option C does not promote the client's independence and should be avoided unless absolutely necessary.
5. What are the clinical manifestations of left-sided heart failure, and how do they differ from right-sided heart failure?
- A. Jugular venous distention and hepatojugular reflex
- B. Hepatomegaly, ascites, and peripheral edema
- C. Dyspnea, cough, and orthopnea
- D. Pulmonary congestion and fatigue
Correct answer: A
Rationale: The correct answer is A. Clinical manifestations of left-sided heart failure include pulmonary symptoms such as dyspnea, cough, and orthopnea. However, left-sided heart failure can also manifest as jugular venous distention and hepatojugular reflex due to the backflow of blood into the pulmonary circulation. Right-sided heart failure is characterized by systemic symptoms like hepatomegaly, ascites, and peripheral edema. Choice B is incorrect as it presents manifestations of right-sided heart failure. Choice C includes symptoms of left-sided heart failure. Choice D describes pulmonary congestion, which is more specific to left-sided heart failure, but it does not encompass the full range of clinical manifestations for left-sided heart failure.
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