ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent infection?
- A. Change the catheter every 72 hours.
- B. Ensure the tubing is unkinked.
- C. Empty the drainage bag every 4 hours.
- D. Hang the drainage bag below the bladder.
Correct answer: D
Rationale: The correct answer is to hang the drainage bag below the bladder. This positioning helps prevent backflow of urine, reducing the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may increase infection risk by introducing pathogens. Ensuring the tubing is unkinked promotes proper urine flow but does not directly prevent infection. Emptying the drainage bag regularly is important to prevent urinary stasis but does not directly address infection prevention.
2. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?
- A. Hypertension, bradycardia, and oliguria
- B. Bradycardia, hypertension, and peripheral edema
- C. Tachypnea, cool skin, and confusion
- D. Tachycardia, hypotension, and decreased urine output
Correct answer: D
Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.
3. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?
- A. Administer emergency medications without performing CPR
- B. Begin CPR
- C. Call the provider for a do-not-resuscitate (DNR) order
- D. Respect the client's wishes, and do not attempt CPR
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.
4. A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?
- A. Sit the client upright
- B. Stop the TPN infusion
- C. Turn the client on their left side
- D. Prepare to add insulin to the TPN infusion
Correct answer: B
Rationale: The correct action for the nurse to take when finding that the TPN solution is infusing too rapidly is to stop the TPN infusion. This is crucial to prevent fluid overload and ensure the client's safety. Sitting the client upright (Choice A) or turning the client on their left side (Choice C) are not appropriate responses to a rapidly infusing TPN solution and do not address the immediate issue of preventing complications from the rapid infusion. Adding insulin to the TPN infusion (Choice D) is not indicated unless specifically prescribed by the healthcare provider for the client's condition. Therefore, the priority action is to stop the TPN infusion to prevent potential harm.
5. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?
- A. Closes the door to the client's room
- B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
- C. Measures the client's vital signs routinely
- D. Asks a group of personnel in the hall to speak quietly
Correct answer: B
Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.
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