ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A patient is prescribed a diuretic for hypertension. What is the most important assessment the nurse should perform?
- A. Monitor the patient's respiratory rate.
- B. Check the patient's blood pressure regularly.
- C. Monitor the patient's potassium levels.
- D. Monitor the patient's sodium levels.
Correct answer: D
Rationale: Corrected Rationale: When a patient is prescribed a diuretic for hypertension, monitoring the patient's sodium levels is crucial. Diuretics can lead to alterations in sodium levels, potentially causing complications like hyponatremia. While monitoring other parameters like respiratory rate, blood pressure, and potassium levels may also be important, the primary concern with diuretic therapy is the risk of sodium imbalance, making the monitoring of sodium levels the most critical assessment.
2. A client with leukemia is considered for a bone marrow transplant. Which principle of healthcare ethics is being practiced by minimizing harm to the client?
- A. Justice
- B. Beneficence
- C. Nonmaleficence
- D. Autonomy
Correct answer: C
Rationale: The correct answer is C: Nonmaleficence. Nonmaleficence is the ethical principle that focuses on avoiding harm to the patient. In this scenario, by considering a bone marrow transplant for the client with leukemia, healthcare professionals are practicing nonmaleficence by aiming to minimize harm. Choice A, Justice, pertains to fairness in the distribution of resources and decisions, which is not the primary focus in this situation. Choice B, Beneficence, involves promoting the patient's well-being, which is related but not directly addressing the act of minimizing harm. Choice D, Autonomy, refers to respecting the patient's right to make decisions about their own care, which is not the key principle at play when minimizing harm in this context.
3. The nurse is evaluating the effectiveness of guided imagery for pain management in a patient with second- and third-degree burns requiring extensive dressing changes. Which finding best indicates the effectiveness of guided imagery?
- A. The patient's need for analgesic medication decreases during the dressing changes.
- B. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.
- C. The patient asks for pain medication during the dressing changes only once throughout the procedure.
- D. The patient's facial expressions remain stoic during the procedure.
Correct answer: A
Rationale: The correct answer is A. A reduction in the need for analgesic medication indicates that guided imagery is effective in managing the patient's pain. Choices B, C, and D do not directly measure the effectiveness of guided imagery. A patient rating pain as 6 on a scale of 0 to 10, asking for pain medication once, or having stoic facial expressions may not necessarily reflect the impact of guided imagery on pain management.
4. In a disaster where a building has collapsed, which victim should a nurse attend to first?
- A. A victim who has died of multiple serious injuries
- B. A victim with a partial amputation of a leg who is bleeding profusely
- C. An alert victim who has numerous bruises on the arms and legs
- D. A hysterical victim who has sustained a head injury
Correct answer: B
Rationale: In a disaster situation like a building collapse, the nurse should attend to the victim with a partial amputation of a leg who is bleeding profusely first. This victim is at immediate risk of severe blood loss, which can be life-threatening. It is crucial to address life-threatening injuries like severe bleeding before attending to other less urgent cases. The victim with the amputation requires immediate intervention to control bleeding and stabilize their condition. Victims who are already deceased or have less urgent injuries can be attended to after addressing the critical cases.
5. A client who had a stroke is complaining of left-side weakness. What should the nurse prioritize?
- A. Initiate physical therapy immediately.
- B. Contact the physical therapy team.
- C. Reassess the client after administering pain medication.
- D. Start treatment immediately without consulting anyone.
Correct answer: B
Rationale: The correct answer is to contact the physical therapy team. When a client who had a stroke presents with left-side weakness, the nurse should prioritize coordinating with the physical therapy team rather than immediately initiating physical therapy. The initial step should involve assessing the client's condition and involving the appropriate healthcare team for a comprehensive care plan. Administering pain medication or starting treatment without consulting others can delay or hinder the appropriate care needed for the client's recovery.
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