ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. 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.
2. The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process?
- A. Do you have any children living in your home?
- B. Do you have a spouse?
- C. Do you have a chronic disease?
- D. Do you have any religious beliefs that will influence your care?
Correct answer: C
Rationale: The correct answer is C: 'Do you have a chronic disease?' Patients with chronic diseases are more susceptible to infections due to factors like general debilitation and nutritional impairment. Choices A, B, and D are incorrect because having children in the home, having a spouse, or religious beliefs do not directly impact susceptibility to infectious diseases.
3. A patient has a DNR (do-not-resuscitate) order but their family insists on resuscitation if necessary. What should the nurse do?
- A. Follow the family's wishes to resuscitate.
- B. Explain that the nurse must follow the DNR order.
- C. Ask the provider for clarification on the DNR.
- D. Call the ethics committee to discuss the situation.
Correct answer: B
Rationale: The correct answer is B. The nurse must follow the legal DNR order, even if the family insists on resuscitation. Respecting the patient's wishes is crucial in providing ethical care. Choice A is incorrect because the nurse should prioritize the patient's documented wishes over the family's requests. Choice C may cause unnecessary delays in care as the DNR order is a legal document. Choice D is not the initial action to take in this situation; the nurse should first address the conflict between the family's wishes and the patient's DNR order.
4. While providing care to a group of patients, which patient should the nurse see first?
- A. A patient after knee surgery who needs range of motion exercises
- B. A patient on bed rest who has renal calculi and needs to go to the bathroom
- C. A bedridden patient who has a reddened area on the buttocks who needs to be turned
- D. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
Correct answer: D
Rationale: The nurse should see the patient with a hip replacement experiencing chest pain and dyspnea first because these symptoms could indicate a pulmonary embolism, which is a life-threatening condition requiring immediate attention. The other patients also need care, but urgent assessment and intervention are crucial in the case of potential pulmonary embolism to prevent serious complications or death.
5. A patient has difficulty ambulating after surgery. Which action should the nurse take first?
- A. Encourage deep breathing exercises.
- B. Assist the patient in ambulating a short distance.
- C. Call for assistance with ambulation.
- D. Assess the patient's pain level before ambulation.
Correct answer: C
Rationale: The correct first action for the nurse to take when a patient has difficulty ambulating after surgery is to call for assistance with ambulation. This is essential to ensure the safety of the patient and prevent any potential falls or injuries. Encouraging deep breathing exercises (Choice A) may be beneficial but should not be the first priority when the patient is having difficulty walking. Assisting the patient in ambulating a short distance (Choice B) may put both the patient and the nurse at risk if the patient is struggling. Assessing the patient's pain level before ambulation (Choice D) is important but should come after ensuring that the patient can safely ambulate with assistance.
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