ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A client complains of pain in the leg while in skeletal traction. What is the nurse's priority action?
- A. Increase the pain medication immediately
- B. Check for signs of infection
- C. Reposition the client's leg for comfort
- D. Notify the physician of the client's complaints
Correct answer: B
Rationale: The correct answer is B: Check for signs of infection. In skeletal traction, the priority action for the nurse when a client complains of pain in the leg is to first assess for signs of infection. Pain in skeletal traction can be a symptom of infection or other complications, so checking for signs of infection is crucial before considering other interventions. Increasing pain medication immediately (Choice A) may mask the symptoms of an underlying infection. Repositioning the client's leg for comfort (Choice C) may provide temporary relief but does not address the potential underlying issue. Notifying the physician of the client's complaints (Choice D) is important but assessing for infection should come first to ensure timely and appropriate intervention.
2. When caring for a client with major depressive disorder, what is the most appropriate short-term goal for the client?
- A. The client will report a decrease in depressive symptoms.
- B. The client will establish a sleep routine.
- C. The client will improve social interactions.
- D. The client will set realistic goals for the future.
Correct answer: A
Rationale: The most appropriate short-term goal for a client with major depressive disorder is for them to report a decrease in depressive symptoms. This goal is specific, measurable, and achievable, focusing on the primary symptoms of the disorder. By monitoring and assessing the client's self-reported improvement in depressive symptoms, the healthcare team can track progress and adjust interventions accordingly.
3. What is the glomerular filtration rate for patients with stage 5 chronic kidney disease (CKD)?
- A. Less than 15 mL/min/1.73 m²
- B. Less than 30 mL/min/1.73 m²
- C. Less than 90 mL/min/1.73 m²
- D. Less than 125 mL/min/1.73 m²
Correct answer: A: Less than 15 mL/min/1.73 m²
Rationale: In patients with stage 5 chronic kidney disease (CKD), also known as end-stage renal disease, the kidney function is significantly compromised. This severe condition is characterized by a glomerular filtration rate (GFR) of less than 15 mL/min/1.73 m², as correctly stated in choice A. Choices B, C, and D suggest higher GFR values, which are not indicative of stage 5 CKD. Specifically, a GFR of less than 30 mL/min/1.73 m² indicates stage 4 CKD, less than 90 mL/min/1.73 m² signifies stage 3 CKD, and a typical healthy individual usually has a GFR of around 125 mL/min/1.73 m², which is far above the GFR for stage 5 CKD.
4. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure the safety of the client while in the hospital? (Select one that doesn't apply.)
- A. Have suction equipment at the bedside
- B. Keep bed rails up at all times
- C. Ensure that the client has IV access
- D. Maintain the client on strict bed rest
Correct answer: Maintain the client on strict bed rest
Rationale: For a client with epilepsy, it is essential to avoid restraining them with strict bed rest as it can lead to complications like muscle atrophy, thrombosis, and pressure ulcers. Having suction equipment at the bedside is important in case of seizures to prevent aspiration. Keeping bed rails up can prevent falls during a seizure. Ensuring that the client has IV access is crucial for administering medications such as antiepileptic drugs or emergency medications if needed. Therefore, maintaining the client on strict bed rest is not a recommended precaution for a client with epilepsy.
5. A nurse is providing discharge teaching about food choices to a client who has hypokalemia. Which of the following foods should the nurse identify as the best source of potassium?
- A. 1 cup grapes
- B. 1 cup shredded lettuce
- C. 1 cup cooked tomatoes
- D. 1 cup apple slices
Correct answer: C
Rationale: Cooked tomatoes are high in potassium, which is crucial for maintaining normal cell function, nerve transmission, and muscle contraction, making them a suitable choice for addressing hypokalemia. Grapes, shredded lettuce, and apple slices do not contain as much potassium as cooked tomatoes, so they are not the best choice for addressing hypokalemia.
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