ATI RN
ATI Capstone Comprehensive Assessment B
1. The healthcare provider is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate?
- A. What activities, if any, has your pain prevented you from doing?
- B. When does your pain medication typically take effect on your pain?
- C. Would you please rate your pain on a scale from 0 to 10 for me?
- D. Have you considered working with a physical therapist?
Correct answer: A
Rationale: The most appropriate assessment question in this scenario is asking the patient, 'What activities, if any, has your pain prevented you from doing?' This question helps the healthcare provider understand how pain is impacting the patient's daily activities and mobility, providing valuable insight into the limitations caused by the pain. Choice B focuses on pain medication effectiveness, which is not directly related to mobility assessment. Choice C aims at pain intensity assessment but does not directly address mobility issues. Choice D suggests a solution rather than gathering information about the current impact of pain on mobility.
2. The nurse is performing hand hygiene before assisting a healthcare provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next?
- A. Repeat handwashing using antiseptic soap.
- B. Inform the healthcare provider and recruit another nurse to assist.
- C. Extend the handwashing procedure to 5 minutes.
- D. Rinse and dry hands and begin assisting the healthcare provider.
Correct answer: A
Rationale: The correct answer is A. The sink is considered a contaminated area. When hand hygiene is compromised during the process, it is essential to repeat handwashing using antiseptic soap to ensure proper hygiene. Choice B is incorrect because the situation can be managed by proper handwashing. Choice C is incorrect as extending the handwashing procedure to 5 minutes is not necessary in this scenario. Choice D is incorrect as the hands need to be properly cleaned before assisting the healthcare provider.
3. A nurse is caring for a patient who has just returned from surgery. What is the nurse's priority action?
- A. Monitor the patient's pain level.
- B. Assess the patient's vital signs.
- C. Assess the surgical incision site.
- D. Position the patient in a high Fowler's position.
Correct answer: B
Rationale: The correct answer is B: Assess the patient's vital signs. Assessing vital signs is crucial as it helps to detect any early signs of complications such as bleeding, shock, or changes in oxygenation. Monitoring the patient's pain level (Choice A) is important but assessing vital signs takes precedence. While assessing the surgical incision site (Choice C) is essential, ensuring the patient's physiological stability through vital sign assessment is the priority. Positioning the patient in a high Fowler's position (Choice D) may be necessary for comfort but does not address the immediate need to assess the patient's condition post-surgery.
4. A nurse is preparing a client for surgery. The client refuses to remove a religious medal. What is the nurse's best response?
- A. Ask the family to remove the medal
- B. Place the medal in a safe place for the client
- C. Allow the client to keep the medal during surgery
- D. Inform the client that the medal must be removed
Correct answer: C
Rationale: The correct answer is to allow the client to keep the medal during surgery. Clients may retain religious medals or jewelry during surgery if it does not interfere with the procedure. Asking the family to remove the medal (Choice A) may not be respecting the client's wishes. Placing the medal in a safe place for the client (Choice B) may cause distress to the client who wants to keep it. Informing the client that the medal must be removed (Choice D) disregards the client's beliefs and preferences.
5. A client is preparing for a surgical procedure but refuses to remove religious jewelry. What is the best course of action?
- A. Proceed with surgery and document the refusal.
- B. Ask the client for permission to secure the jewelry.
- C. Remove the jewelry and store it safely.
- D. Postpone the surgery until the jewelry is removed.
Correct answer: B
Rationale: The best course of action is to ask the client for permission to secure the jewelry. This respects the client's religious beliefs while also ensuring that the jewelry does not interfere during the surgical procedure. Proceeding with surgery without addressing the presence of the jewelry can lead to complications or distress for the client. Removing the jewelry without consent or postponing the surgery solely due to the presence of religious jewelry are not appropriate actions in this situation.
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