ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A client with a DNR order has requested resuscitation during a visit from the family. What is the nurse's best course of action?
- A. Follow the family's request and perform CPR.
- B. Explain to the family that the DNR must be honored.
- C. Call the healthcare provider to cancel the DNR order.
- D. Delay resuscitation until further clarification can be made.
Correct answer: B
Rationale: The correct course of action for the nurse is to explain to the family that the DNR (Do Not Resuscitate) order must be honored. It is essential for the nurse to uphold the client's wishes as documented in the DNR order. Performing CPR against the client's expressed wishes in the DNR order would violate ethical and legal standards. Calling the healthcare provider to cancel the DNR order without the client's consent is inappropriate and goes against the client's autonomy. Delaying resuscitation can be detrimental in an emergency situation and may not align with the client's wishes as outlined in the DNR order.
2. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?
- A. Do not change the mask if the nurse is comfortable.
- B. Change the mask when relieved by the next shift.
- C. Apply a new mask.
- D. Reapply the mask after it air-dries.
Correct answer: C
Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.
3. The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?
- A. Straps with quick-release buckles attached to bed side rails.
- B. Attempts to distract the patient with television are unsuccessful.
- C. Bilateral radial pulses present, 2+, hands warm to the touch.
- D. Released from restraints, active range-of-motion exercises completed.
Correct answer: C
Rationale: The correct answer is C because documenting bilateral radial pulses being present, 2+, and hands warm to the touch is crucial when caring for a patient in restraints. This information helps in monitoring circulation and assessing the patient's well-being. Choices A, B, and D are incorrect because they do not provide essential information related to the patient's safety and well-being while in restraints.
4. A nurse notices that a colleague has an odor of alcohol while on duty. What is the most appropriate action?
- A. Speak to the colleague in private.
- B. Report the behavior to the nurse manager immediately.
- C. Confront the colleague directly on the floor.
- D. Do nothing and document the situation.
Correct answer: B
Rationale: Reporting the behavior to the nurse manager immediately is the most appropriate action when a nurse suspects a colleague of being impaired while on duty. This is crucial to ensure patient safety and maintain a professional and safe work environment. Speaking to the colleague in private may not address the issue effectively and could potentially put patients at risk if the colleague is indeed impaired. Confronting the colleague directly on the floor may lead to a confrontation and is not the most professional way to handle the situation. Doing nothing and documenting the situation without taking immediate action can jeopardize patient safety and is not an appropriate response when substance use is suspected.
5. What is the priority when assessing a patient for possible deep vein thrombosis (DVT)?
- A. Dorsiflex the foot and check for pain.
- B. Measure the calf circumference of both legs.
- C. Check the skin for signs of redness.
- D. Perform a Doppler ultrasound scan.
Correct answer: B
Rationale: The correct answer is to measure the calf circumference of both legs when assessing a patient for possible DVT. An increase in calf circumference in one leg can indicate the presence of a DVT. Option A is incorrect because dorsiflexing the foot and checking for pain are not primary assessments for DVT. Option C is incorrect as redness of the skin may not always be present in cases of DVT. Option D is incorrect as performing a Doppler ultrasound scan is usually done after clinical assessment and to confirm the diagnosis, not as the initial priority assessment.
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