ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. Which intervention should be prioritized for a client experiencing panic-level anxiety?
- A. Postpone health teaching until anxiety subsides
- B. Encourage participation in group therapy
- C. Monitor vital signs every 5 minutes
- D. Provide reassurance and remain with the client
Correct answer: D
Rationale: During panic-level anxiety, the priority is to provide reassurance and remain with the client. This intervention helps to offer immediate support, comfort, and a sense of safety to the client. Postponing health teaching until anxiety subsides (Choice A) is not appropriate as the client's immediate emotional needs are more critical. Encouraging participation in group therapy (Choice B) may be beneficial in the long term but is not the priority during a panic attack. While monitoring vital signs (Choice C) is important, providing reassurance and support take precedence in managing panic-level anxiety.
2. A nurse is caring for a client following an esophagogastroduodenoscopy (EGD). Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Pain
- C. Nausea
- D. Gag reflex
Correct answer: D
Rationale: The correct answer is assessing the gag reflex. This is the priority assessment following an EGD procedure to prevent aspiration. Checking the gag reflex helps ensure the client's airway protection. Assessing the level of consciousness is important, but ensuring the client can protect their airway takes precedence. Pain and nausea assessments are also essential but are secondary to maintaining airway patency.
3. 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.
4. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?
- A. Drink fluids between meals
- B. Eat three large meals each day
- C. Lie down for 30 minutes after meals
- D. Avoid drinking liquids with meals
Correct answer: D
Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.
5. A patient with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. What is the most appropriate action to improve the patient's oxygenation?
- A. Encourage the patient to use incentive spirometry.
- B. Administer oxygen via nasal cannula as prescribed.
- C. Assist the patient with coughing and deep breathing exercises.
- D. Position the patient in a high Fowler's position.
Correct answer: B
Rationale: Administering oxygen via nasal cannula as prescribed is the most appropriate action to improve the patient's oxygenation in COPD. Oxygen therapy helps maintain adequate oxygen levels in the blood, which is crucial for managing COPD. Encouraging the use of incentive spirometry, assisting with coughing and deep breathing exercises, and positioning the patient in high Fowler's position are all beneficial interventions, but administering oxygen is the priority for immediate oxygenation support in COPD.
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