ATI RN
ATI Capstone Comprehensive Assessment B
1. What is the most important nursing intervention for a patient with diarrhea?
- A. Encourage the patient to increase fluid intake.
- B. Monitor the patient's skin integrity.
- C. Check the patient's electrolyte levels.
- D. Educate the patient about infection control measures.
Correct answer: B
Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.
2. What is the priority nursing intervention for a patient with a new tracheostomy?
- A. Suction the tracheostomy as needed to maintain a patent airway.
- B. Monitor the patient's oxygen saturation.
- C. Provide humidified air to prevent drying of the airway.
- D. Administer pain medication as prescribed.
Correct answer: A
Rationale: The correct answer is to suction the tracheostomy as needed to maintain a patent airway. After a tracheostomy procedure, the immediate concern is airway patency to prevent respiratory compromise. Suctioning helps clear secretions and maintains a clear airway, reducing the risk of respiratory distress. Monitoring the patient's oxygen saturation (choice B) is important but not the priority compared to ensuring a clear airway. Providing humidified air (choice C) and administering pain medication (choice D) are also essential aspects of care for a patient with a tracheostomy, but they are not the priority when immediate airway management is required.
3. A family was referred to crisis intervention services after a natural disaster. One family member refuses to attend, stating, 'No way, I'm not crazy.' What is the nurse's best response?
- A. Don't worry now. The psychiatrists are well trained to help.
- B. Many times, disasters can create mental health problems, so you really should participate with your family.
- C. This will help your family communicate better.
- D. Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.
Correct answer: D
Rationale: The nurse should reassure the family member that seeking help does not imply mental illness, but is part of coping with the disaster.
4. A patient recovering from a stroke has difficulty swallowing. Which action should the nurse prioritize?
- A. Begin feeding the patient soft solids.
- B. Place the patient on NPO (nothing by mouth) status.
- C. Provide ice chips to help soothe the throat.
- D. Start the patient on a clear liquid diet.
Correct answer: B
Rationale: The correct answer is to place the patient on NPO (nothing by mouth) status. Patients recovering from a stroke with difficulty swallowing are at high risk for aspiration, which can lead to serious complications like aspiration pneumonia. Therefore, the priority is to keep the patient on NPO until a thorough evaluation by a healthcare provider is completed. Choice A is incorrect as feeding the patient soft solids can increase the risk of aspiration. Choice C is incorrect as providing ice chips may further compromise swallowing safety. Choice D is incorrect as starting the patient on a clear liquid diet can also increase the risk of aspiration in this scenario.
5. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?
- A. Place the call light within the patient's reach.
- B. Apply a yellow fall risk bracelet to the patient.
- C. Assist the patient when ambulating.
- D. Ensure the patient's room is well-lit.
Correct answer: B
Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.
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