ATI RN
ATI Capstone Comprehensive Assessment B
1. What intervention should the nurse implement for a patient receiving a blood transfusion?
- A. Administer antihistamines to prevent allergic reactions.
- B. Monitor the patient for signs of circulatory overload.
- C. Ensure the blood transfusion is completed within 4 hours.
- D. Check the patient's vital signs every 30 minutes during the transfusion.
Correct answer: B
Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.
2. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?
- A. CT scan
- B. MRI
- C. X-ray
- D. Ultrasound
Correct answer: A
Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.
3. A patient has a new prescription for allopurinol to treat gout. What should the nurse include in the teaching?
- A. Decrease protein intake
- B. Limit salt intake
- C. Increase fluid intake
- D. Limit alcohol
Correct answer: C
Rationale: Correct answer: Increasing fluid intake is essential when taking allopurinol to prevent kidney stones and aid in uric acid excretion. This helps reduce the risk of developing complications associated with gout. Decreasing protein intake (Choice A) is not directly related to allopurinol therapy. Limiting salt intake (Choice B) and alcohol consumption (Choice D) are important for overall health but are not specific recommendations when taking allopurinol for gout.
4. A nurse is preparing a client for surgery. Which of the following actions should be taken first?
- A. Ensure informed consent is signed
- B. Start IV fluids
- C. Administer preoperative antibiotics
- D. Reinforce surgical site dressing
Correct answer: A
Rationale: The correct answer is to ensure informed consent is signed first when preparing a client for surgery. This step is crucial as it ensures that the client has been informed about the procedure, risks, benefits, and alternatives before giving consent. Starting IV fluids (choice B) may be necessary but comes after obtaining informed consent. Administering preoperative antibiotics (choice C) is important but typically follows confirming informed consent. Reinforcing surgical site dressing (choice D) is a postoperative step and does not take precedence over obtaining informed consent.
5. A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medications should the nurse include under Schedule II?
- A. Buprenorphine hydrochloride
- B. Hydrocodone bitartrate
- C. Diazepam
- D. Morphine
Correct answer: B
Rationale: The correct answer is B: Hydrocodone bitartrate. According to the Controlled Substances Act, hydrocodone bitartrate is classified as a Schedule II controlled substance due to its high potential for abuse and addiction. Diazepam (Choice C) and morphine (Choice D) are classified as Schedule IV and Schedule II controlled substances, respectively. Buprenorphine hydrochloride (Choice A) is classified as a Schedule III controlled substance. Therefore, hydrocodone bitartrate should be included under Schedule II medications when discussing the categories regulated under the Controlled Substances Act.
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