ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A client requires suctioning every 2 hours. To whom should the nurse delegate this task?
- A. Delegate to a licensed practical nurse (LPN)
- B. Delegate to a registered nurse (RN)
- C. Delegate to a nursing assistant (NA)
- D. Perform the task independently
Correct answer: A
Rationale: The correct answer is to delegate the task to a licensed practical nurse (LPN). LPNs can typically perform suctioning, but it is essential to consider the state's practice guidelines and hospital policy. Option B, delegating to a registered nurse (RN), is not necessary for this task as LPNs are usually competent to handle suctioning. Option C, delegating to a nursing assistant (NA), may not be appropriate as suctioning may require a higher level of training and expertise. Option D, performing the task independently, is not the best choice as delegation is a key aspect of nursing practice to ensure tasks are appropriately assigned based on competency levels.
2. A healthcare provider is assessing a patient with chronic pain. Which finding is most concerning?
- A. The patient reports a pain level of 6 on a scale of 0 to 10.
- B. The patient is lying still and refuses to move.
- C. The patient's pain persists despite medication.
- D. The patient reports feeling anxious and restless.
Correct answer: C
Rationale: In the context of chronic pain management, the most concerning finding is when the patient's pain persists despite medication. This suggests inadequate pain control or the need for a re-evaluation of the treatment plan. Choices A, B, and D are not as concerning in this scenario. A pain level of 6 on a scale of 0 to 10 is moderate and may be manageable with appropriate interventions. Patients with chronic pain can sometimes lie still due to pain or other reasons, and anxiety and restlessness are common in individuals with pain conditions but may not necessarily indicate a critical issue like uncontrolled pain.
3. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?
- A. Hypertension, bradycardia, and oliguria
- B. Bradycardia, hypertension, and peripheral edema
- C. Tachypnea, cool skin, and confusion
- D. Tachycardia, hypotension, and decreased urine output
Correct answer: D
Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.
4. A nurse is caring for a client who is postoperative and has compression stockings. Which action should the nurse take?
- A. Check the stockings for wrinkles
- B. Apply the stockings while the client is sitting in a chair
- C. Measure the size of the client's foot
- D. Remove the stockings once each day
Correct answer: A
Rationale: The correct action for the nurse to take is to check the stockings for wrinkles. This is important to ensure that the stockings are applied correctly without any folds or wrinkles, which can hinder proper circulation and compression. Option B is incorrect because compression stockings should be applied with the client lying down, not sitting in a chair. Option C is unnecessary as the size of the client's foot is unlikely to change postoperatively. Option D is incorrect as compression stockings are usually worn continuously except for specific care needs.
5. A nurse is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer?
- A. 1
- B. 2
- C. 3
- D. 4
Correct answer: B
Rationale: The correct answer is B: 2. To achieve the prescribed dose of 0.25 mg of digoxin, the nurse should administer two 0.125 mg tablets. This calculation ensures that the patient receives the correct amount of medication. Choices A, C, and D are incorrect because they do not reflect the accurate dosage needed based on the available tablets and prescribed dose.
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