ATI RN
ATI Capstone Comprehensive Assessment B
1. If a client refuses surgery, but the family insists, what should the nurse do in this situation?
- A. Respect the family's decision and proceed with the surgery.
- B. Respect the client's decision and notify the healthcare provider.
- C. Try to mediate between the family and the client.
- D. Encourage the client to follow their family's wishes.
Correct answer: B
Rationale: In this situation, the nurse should respect the client's decision and notify the healthcare provider. The client has the right to refuse treatment, and the nurse must advocate for the client's autonomy. Proceeding with the surgery against the client's wishes would violate their autonomy and ethical principles. Trying to mediate between the family and the client may be appropriate, but ultimately, the client's decision should be respected. Encouraging the client to follow their family's wishes disregards the client's autonomy and is not ethically appropriate.
2. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?
- A. Wear a gown, gloves, face mask, and goggles for interactions with the patient.
- B. Transport the patient safely and quickly when going to the radiology department.
- C. Place the patient in a room with negative airflow.
- D. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.
Correct answer: D
Rationale: The correct answer is to use a dedicated blood pressure cuff that stays in the room and is used for that patient only. Patients on contact precautions require dedicated equipment to prevent the spread of disease. Using one blood pressure cuff exclusively for the patient on contact precautions helps minimize the risk of transmitting infections to other patients. Choices A, B, and C are incorrect because while wearing protective gear and isolating the patient in a room with negative airflow are important infection control measures, using dedicated equipment for the patient on contact precautions is specifically recommended to prevent the spread of disease in this scenario.
3. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?
- A. Wear gloves when entering the patient's room.
- B. Place the patient in a private room.
- C. Use a dedicated blood pressure cuff for the patient.
- D. Dispose of all equipment in a biohazard bag.
Correct answer: A
Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.
4. A client with severe dyspnea is scheduled for multiple diagnostic tests. Which test should the nurse prioritize?
- A. Administer an echocardiogram first.
- B. Prioritize a chest x-ray for the client.
- C. Prepare the client for a CT scan.
- D. Order an MRI first.
Correct answer: B
Rationale: The correct answer is B: Prioritize a chest x-ray for the client. When a client presents with severe dyspnea, a chest x-ray should be prioritized as it helps in assessing the lungs and heart, which are crucial in cases of respiratory distress. Echocardiograms are more focused on assessing heart function and may not provide immediate information needed in cases of dyspnea. CT scans and MRIs are more detailed imaging studies that are not typically the first-line diagnostic tests for severe dyspnea.
5. A client has a new prescription for lisinopril. Which of the following statements indicates an understanding of the teaching?
- A. I should take this medication with food
- B. I should report a cough to my provider
- C. I should expect to have facial swelling when taking this medication
- D. I should increase my intake of potassium-rich foods
Correct answer: B
Rationale: The correct answer is B. Reporting a cough is crucial when taking lisinopril as it can be a sign of a serious side effect, such as angioedema or cough associated with ACE inhibitors. Option A is incorrect because lisinopril can be taken with or without food. Option C is incorrect as facial swelling is not an expected side effect of lisinopril. Option D is incorrect because lisinopril can cause hyperkalemia, so increasing potassium-rich foods without healthcare provider guidance can be dangerous.
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