ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A charge nurse is discussing HIPAA with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching as an example of a HIPAA violation?
- A. Posting the name of the nurse providing care on a client's communication board
- B. Discussing the client's new medication with a hospital pharmacist
- C. Faxing requested medical information for a client who is transferring to another facility
- D. Emailing the client's positive hepatitis results from an unencrypted server
Correct answer: D
Rationale: The correct answer is D. Emailing client information through an unencrypted server is a HIPAA violation because it can lead to data breaches. Choices A, B, and C do not violate HIPAA. Posting the name of the nurse providing care on a client's communication board does not disclose sensitive health information. Discussing the client's new medication with a hospital pharmacist is a routine healthcare practice. Faxing requested medical information for a client who is transferring to another facility is a secure way to transmit healthcare data.
2. How should a healthcare professional manage a patient with a chest tube?
- A. Ensuring the chest tube is secured properly and functioning
- B. Checking for air leaks and ensuring drainage is working
- C. Ensuring chest tube drainage is below chest level
- D. Ensuring proper documentation of chest tube output
Correct answer: D
Rationale: Proper documentation of chest tube output is crucial in the care of a patient with a chest tube. While ensuring the chest tube is secured and functioning, checking for air leaks, and maintaining drainage below chest level are important aspects of care, documentation of output is essential for monitoring the patient's condition, assessing the effectiveness of treatment, and ensuring appropriate interventions if needed.
3. How should a healthcare provider respond to a patient who is exhibiting signs of acute myocardial infarction (AMI)?
- A. Calling for emergency assistance immediately
- B. Administering nitroglycerin as prescribed
- C. Monitoring the patient's cardiac rhythm
- D. Administering oxygen and preparing for ECG
Correct answer: A
Rationale: When a patient is exhibiting signs of acute myocardial infarction (AMI), the priority action is to call for emergency assistance immediately. This ensures that the patient receives prompt and appropriate care, including interventions such as administering oxygen, nitroglycerin, and monitoring cardiac rhythm. Administering nitroglycerin should only be done if prescribed by a healthcare provider after assessment and confirmation of AMI. Monitoring the patient's cardiac rhythm is important but not the initial action needed in this critical situation. Administering oxygen and preparing for an ECG are important interventions but should follow the immediate step of calling for emergency assistance.
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 who had a stroke is complaining of left-side weakness. What should the nurse prioritize?
- A. Initiate physical therapy immediately.
- B. Contact the physical therapy team.
- C. Reassess the client after administering pain medication.
- D. Start treatment immediately without consulting anyone.
Correct answer: B
Rationale: The correct answer is to contact the physical therapy team. When a client who had a stroke presents with left-side weakness, the nurse should prioritize coordinating with the physical therapy team rather than immediately initiating physical therapy. The initial step should involve assessing the client's condition and involving the appropriate healthcare team for a comprehensive care plan. Administering pain medication or starting treatment without consulting others can delay or hinder the appropriate care needed for the client's recovery.
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