ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?
- A. Lock beds and wheelchairs when not in use
- B. Administer a sedative at bedtime
- C. Provide information about home safety checks
- D. Teach balance and strengthening exercises
Correct answer: A
Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.
2. A client is experiencing chest pain. Which action should the nurse take first?
- A. Administer aspirin
- B. Provide oxygen
- C. Perform an ECG
- D. Administer nitroglycerin
Correct answer: D
Rationale: Administering nitroglycerin is the priority action when a client is experiencing chest pain as it helps alleviate the pain caused by reduced blood flow to the heart. Oxygen can be beneficial, but nitroglycerin takes precedence in this situation. Aspirin can also be given, but nitroglycerin is the priority. Performing an ECG can provide valuable information but is not the first action to take in this scenario.
3. How can a healthcare professional help prevent pressure ulcers in an immobile patient?
- A. Ensuring proper nutrition and hydration
- B. Using moisture barriers to protect the skin
- C. Turning the patient every 2 hours to prevent pressure
- D. Providing special mattresses or padding
Correct answer: A
Rationale: Ensuring proper nutrition and hydration is crucial in preventing pressure ulcers in immobile patients. Adequate nutrition supports tissue health and repair, while hydration helps maintain skin elasticity. While turning the patient every 2 hours is important to prevent pressure injuries, it is not the primary way to address prevention. Using moisture barriers and providing special mattresses or padding are essential components of pressure ulcer prevention, but they are not as fundamental as ensuring proper nutrition and hydration.
4. What is an appropriate parenting technique for time-out disciplining in children with mental health issues?
- A. Provide positive reinforcement for minor infractions
- B. Remove all privileges for at least one week following a violation
- C. Limit the child's time outside of the home environment
- D. Time-out should only be used in severe situations
Correct answer: B
Rationale: The correct answer is B: 'Remove all privileges for at least one week following a violation.' When dealing with children with mental health issues, it is essential to have consistent consequences for their actions. Providing positive reinforcement for minor infractions (choice A) may not effectively address inappropriate behaviors that require disciplinary action. Limiting the child's time outside the home environment (choice C) does not directly address the behavioral issue. Using time-out only in severe situations (choice D) may not provide consistent consequences for the child's behavior and can lead to escalation before interventions are used.
5. 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.
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