ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. Which intervention will best help a patient with chronic pain maintain mobility?
- A. Provide the patient with opioids to control pain.
- B. Encourage stretching exercises to improve flexibility.
- C. Teach the patient to use assistive devices like a cane.
- D. Recommend complete bed rest until the pain subsides.
Correct answer: B
Rationale: Encouraging stretching exercises is the most appropriate nursing intervention to help a patient with chronic pain maintain mobility. Stretching exercises can improve flexibility, prevent stiffness, and promote better range of motion in patients with chronic pain. Providing opioids (Choice A) may help control pain but does not directly address mobility. Teaching the patient to use assistive devices (Choice C) may be beneficial but does not focus on improving mobility directly. Recommending complete bed rest (Choice D) can lead to deconditioning and further loss of mobility, which is not recommended for chronic pain management.
2. A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?
- A. 2
- B. 3
- C. 4
- D. 5
Correct answer: C
Rationale: To calculate the mL needed, divide the total dose by the dose per mL. In this case, 40 mg divided by 10 mg/mL equals 4 mL. Therefore, the nurse should administer 4 mL per dose. Choice A, 2 mL, is incorrect because it would only deliver 20 mg of furosemide, which is half the required dose. Choices B and D are also incorrect as they do not provide the accurate amount needed to achieve the 40 mg dosage.
3. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Giving a glycerin suppository to a client for constipation
- B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache
- C. Discussing dietary changes with a client who has a prescription for a gluten-free diet
- D. Measuring hourly urinary output for a client who is postoperative
Correct answer: D
Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.
4. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?
- A. Provide assistance to the bathroom
- B. Insert a straight catheter
- C. Increase fluids
- D. Perform a bladder scan
Correct answer: D
Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.
5. When administering an IM injection into a client's deltoid muscle, which of the following actions should the nurse take?
- A. Use a 21-gauge needle for the injection
- B. Inject the medication at a 90-degree angle
- C. Inject the medication 12.7 cm (5 in) below the acromion process
- D. Inject the medication 2.54 cm (1 in) below the acromion process
Correct answer: B
Rationale: The correct answer is to inject the medication at a 90-degree angle when administering an IM injection into the deltoid muscle. This angle ensures proper delivery of the medication into the muscle tissue. Choice A is incorrect because the gauge of the needle for a deltoid IM injection is usually smaller, around 23-25 gauge. Choices C and D are incorrect as the injection site for the deltoid muscle is approximately 2.54 cm (1 in) below the acromion process, not 12.7 cm (5 in).
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