ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A client expresses concern about hair loss during chemotherapy. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy begins.
- B. Offer resources for wigs and head coverings.
- C. Assure the client that hair loss will be minimal.
- D. Ignore the client's concerns about hair loss.
Correct answer: B
Rationale: During chemotherapy, hair loss is a common side effect. Offering resources for wigs and head coverings can help the client cope with this change in appearance, maintain self-esteem, and feel more comfortable during the process. Encouraging the client to cut their hair short does not address the emotional impact of hair loss and may not be the client's preference. Assuring the client that hair loss will be minimal may provide false hope as significant hair loss is a common occurrence. Ignoring the client's concerns is not appropriate and goes against the principles of providing holistic and compassionate care.
2. A nurse is teaching a patient with hypertension about the DASH diet. What is the most important instruction to include?
- A. Increase the patient's intake of fruits and vegetables.
- B. Limit the patient's intake of saturated fats.
- C. Encourage the patient to reduce sodium intake.
- D. Recommend the patient avoid caffeine.
Correct answer: C
Rationale: The correct answer is to encourage the patient to reduce sodium intake. The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes reducing sodium intake to help manage hypertension. While increasing fruits and vegetables (Choice A) is important in the DASH diet, reducing sodium intake is considered more crucial. Limiting saturated fats (Choice B) is beneficial but not as critical as reducing sodium. Avoiding caffeine (Choice D) is not a specific recommendation of the DASH diet for managing hypertension.
3. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?
- A. White blood cell count (WBC)
- B. C-reactive protein (CRP)
- C. Erythrocyte sedimentation rate (ESR)
- D. Hemoglobin and hematocrit levels
Correct answer: A
Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.
4. A nurse in the PACU is caring for a client who has received general anesthesia and has a manifestation of malignant hyperthermia. The nurse should expect to administer which of the following medications?
- A. Acetaminophen
- B. Ibuprofen
- C. Dantrolene
- D. Diazepam
Correct answer: C
Rationale: Corrected Rationale: Dantrolene is the medication of choice to treat malignant hyperthermia, a life-threatening reaction to general anesthesia. It works by inhibiting the release of calcium ions in skeletal muscle cells, preventing muscle contracture and hypermetabolism. Acetaminophen (Choice A) and ibuprofen (Choice B) are not indicated for treating malignant hyperthermia. Diazepam (Choice D) may be used to control muscle spasms but is not the first-line treatment for malignant hyperthermia.
5. A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
- A. Finger
- B. Earlobe
- C. Toe
- D. Skin fold
Correct answer: B
Rationale: When a client has edema of both hands and thickened toenails, these conditions can impede accurate readings from the finger and toe locations. The earlobe is the best alternative site for the pulse oximeter probe in this scenario. Placing the probe on the earlobe will help ensure a more accurate measurement of oxygen saturation despite the issues with the hands and toenails. Therefore, the correct answer is to apply the pulse oximeter probe to the earlobe. Choices A, C, and D are incorrect because of the potential limitations presented by the edema and thickened toenails.
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