ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?
- A. Choosing a fresh pear would be a good snack option
- B. I should make refried beans for supper
- C. Selecting white rice as a side dish is a good choice
- D. Opting for bran cereal would be a good breakfast choice
Correct answer: C
Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.
2. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?
- A. Positioning the patient in a prone position
- B. Monitoring vital signs and lung sounds
- C. Preparing for mechanical ventilation
- D. Administering supplemental oxygen
Correct answer: A
Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.
3. A client has a prescription for vancomycin 1g IV intermittent infusion over 30 minutes every 12 hours. What action should the nurse take?
- A. Start the infusion immediately
- B. Slow down the infusion rate
- C. Contact the provider for prescription clarification
- D. Check blood pressure during the infusion
Correct answer: C
Rationale: The correct action for the nurse to take is to contact the provider for prescription clarification. Administering vancomycin over less than 60 minutes can lead to infusion reactions like hypotension and flushing. Starting the infusion immediately (choice A) is incorrect as it goes against the prescribed rate. Slowing down the infusion rate (choice B) without provider approval can result in underdosing the medication. Checking blood pressure during the infusion (choice D) is important but not the most immediate action needed in this situation.
4. A nurse is caring for a female client who has osteoporosis and a new prescription for raloxifene. What should the nurse assess prior to initiating therapy?
- A. Pregnancy status
- B. Bone density
- C. Calcium levels
- D. Blood pressure
Correct answer: A
Rationale: The correct answer is A: Pregnancy status. Raloxifene is a pregnancy category X drug, which means it can cause serious birth defects. Therefore, it is crucial for the nurse to assess the client's pregnancy status before initiating therapy. Choice B, bone density, while important in osteoporosis management, is not a specific concern related to initiating raloxifene therapy. Choice C, calcium levels, and choice D, blood pressure, are not directly related to the initiation of raloxifene therapy in a female client with osteoporosis.
5. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
- A. Cleanse the bag every 24 hours
- B. Cleanse the bag every 48 hours
- C. Use tap water
- D. Flush the tube every 4 hours
Correct answer: A
Rationale: The correct answer is A. Cleansing the bag every 24 hours can lead to contamination, increasing the risk of infection and diarrhea. Using tap water (choice C) is not recommended for cleaning the gastrostomy tube due to the risk of introducing harmful microorganisms. Cleansing the bag every 48 hours (choice B) is not frequent enough and may also contribute to infection. Flushing the tube every 4 hours (choice D) is a standard practice to ensure patency and should not be intervened by the nurse.
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