ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?
- A. Loud volume of the television set
- B. Wall-to-wall carpet in the living room
- C. Low chairs without armrests
- D. Use of indirect lighting
Correct answer: C
Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.
2. A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Suggest that the client use a salt substitute
- B. Obtain a 12-lead ECG
- C. Obtain a blood sample for a serum sodium level
- D. Advise the client to add citrus juices and bananas to their diet
Correct answer: B
Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.
3. A healthcare provider is reviewing the medical record of a client who has a new prescription for cimetidine. Which of the following laboratory findings should the healthcare provider identify as the priority to report to the provider?
- A. Sodium 140 mEq/L
- B. WBC count 9,000/mm3
- C. Aspartate aminotransferase (AST) 50 units/L
- D. Fasting glucose 105 mg/dL
Correct answer: C
Rationale: An elevated AST level is indicative of liver damage, which is the priority finding to report to the provider when administering cimetidine. Elevated liver enzymes can be a sign of liver toxicity or damage. Monitoring liver function is crucial when using cimetidine, as it can sometimes lead to hepatotoxicity. The other laboratory findings are within normal ranges and not directly associated with cimetidine administration.
4. How can dehydration be assessed in an elderly patient?
- A. Checking skin turgor on the forearm
- B. Assessing for dry mucous membranes
- C. Checking for orthostatic hypotension
- D. Measuring daily weights
Correct answer: A
Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.
5. When working with a client who does not speak the same language, which of the following actions should the nurse take?
- A. Speak directly to the interpreter
- B. Use family members to translate
- C. Speak directly to the patient
- D. Use medical jargon
Correct answer: C
Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.
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