ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A nurse manager is implementing a quality improvement project to reduce the number of methicillin-resistant Staphylococcus aureus (MRSA) infections at the facility. Which of the following actions should the nurse manager take first?
- A. Develop an MRSA protocol for implementation.
- B. Provide educational in-services for staff.
- C. Evaluate outcomes resulting from interventions.
- D. Conduct a chart review to evaluate precipitating factors of clients who develop MRSA.
Correct answer: D
Rationale: Conducting a chart review to evaluate the precipitating factors of clients who develop MRSA is the initial step in reducing these infections. By identifying factors contributing to MRSA infections, the nurse manager can develop targeted interventions. Developing an MRSA protocol (choice A) and providing educational in-services (choice B) would be premature without understanding the specific factors at play. Evaluating outcomes (choice C) should come after implementing interventions based on the findings from the chart review.
2. A patient prescribed warfarin is being taught about dietary restrictions by a healthcare provider. Which of the following foods should the patient be instructed to limit?
- A. Bananas
- B. Spinach
- C. Potatoes
- D. Apples
Correct answer: B
Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which can interfere with the effectiveness of warfarin, an anticoagulant medication. Patients taking warfarin should limit foods high in vitamin K to maintain the medication's effectiveness and consistent dosage. Bananas, potatoes, and apples are not high in vitamin K and do not typically interfere with warfarin therapy.
3. How should a healthcare professional respond to a patient experiencing hypoglycemia?
- A. Rechecking the blood glucose level in 15 minutes
- B. Encouraging the patient to eat a high-protein snack
- C. Administering 15g of fast-acting carbohydrates
- D. Administering glucagon if the patient is unconscious
Correct answer: C
Rationale: The correct response to a patient experiencing hypoglycemia is to administer 15g of fast-acting carbohydrates. This helps quickly increase the blood glucose levels in the patient, addressing the low blood sugar. Rechecking the blood glucose level in 15 minutes (Choice A) may delay necessary intervention, encouraging a high-protein snack (Choice B) is not recommended as it does not rapidly increase blood sugar levels, and administering glucagon if the patient is unconscious (Choice D) is typically done in severe cases of hypoglycemia when the patient is unable to eat or drink.
4. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?
- A. Found on floor
- B. Client slipped while getting out of bed
- C. Patient fell while attempting to get out of bed
- D. Roommate reported fall
Correct answer: A
Rationale: The correct answer is 'A: Found on floor.' This choice provides a clear and objective account of the situation without adding interpretation or assumptions. It is crucial to document only the facts observed directly. Choices B and C introduce speculation by suggesting how the incident happened, which the nurse did not witness. Choice D is not directly related to the nurse’s observation and should not be documented as the primary incident.
5. A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?
- A. Administer an antiemetic to the client
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Provide the client with an emesis basin
Correct answer: C
Rationale: Preventing aspiration is the priority when caring for a client who is vomiting to reduce the risk of pneumonia or other respiratory complications. Aspiration can occur when vomitus enters the airway, leading to respiratory distress. Ensuring the airway is protected during vomiting episodes is essential. Administering an antiemetic (Choice A) can be considered after addressing the immediate risk of aspiration. Notifying housekeeping (Choice B) and providing an emesis basin (Choice D) are important but are secondary to preventing aspiration, which is crucial for the client's safety and well-being.
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