ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy.
- B. Provide resources for wigs or hairpieces.
- C. Assure the client that hair loss will be minimal.
- D. Offer the client medication to reduce the chances of hair loss.
Correct answer: B
Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.
2. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
- A. Check for orthostatic hypotension
- B. Use a gait belt
- C. Position the chair on the strong side
- D. Ask for assistance
Correct answer: A
Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.
3. After a case manager completes a history and physical assessment for a client with COPD, which of the following actions should the case manager take next?
- A. Call the provider with a list of client concerns.
- B. Identify the client's current health needs.
- C. Compile a list of community resources for the client.
- D. Refer the client to a COPD support group.
Correct answer: A
Rationale: After completing a history and physical assessment for a client with COPD, the next step for the case manager should be to call the provider with a list of client concerns. This is crucial as the provider needs to be informed about any issues or changes in the client's health status to ensure appropriate management. Identifying the client's current health needs, as mentioned in option B, is important but would typically follow after communicating the client's concerns to the provider. Compiling a list of community resources (option C) and referring the client to a COPD support group (option D) are also valuable actions but are not the immediate next steps after completing the assessment.
4. A nurse is caring for a client with a new colostomy. What is the nurse's responsibility regarding stoma care?
- A. Educate the client on how to care for the stoma independently.
- B. Contact the stoma nurse to assist the client with care.
- C. Delegate the care of the stoma to a nursing assistant.
- D. Wait until the next shift to address the stoma care.
Correct answer: B
Rationale: The correct answer is to contact the stoma nurse to assist the client with care. Stoma nurses are specially trained to provide guidance on stoma care, especially for clients with new ostomies. Instructing the client to care for the stoma independently (Choice A) may not be appropriate initially as they may need professional guidance. Delegating the care of the stoma to a nursing assistant (Choice C) is not recommended as specialized care is required. Waiting until the next shift (Choice D) is not ideal as stoma care should not be delayed.
5. A healthcare professional is reviewing the lab results of a client with liver disease. Which finding requires immediate intervention?
- A. Elevated bilirubin levels
- B. Low albumin levels
- C. Elevated ammonia levels
- D. Low hemoglobin levels
Correct answer: C
Rationale: Elevated ammonia levels in a client with liver disease can lead to hepatic encephalopathy, requiring immediate intervention. Ammonia is a neurotoxin that can cause cognitive impairment and altered mental status. Elevated bilirubin levels (Choice A) are common in liver disease but do not require immediate intervention. Low albumin levels (Choice B) and low hemoglobin levels (Choice D) are also common in liver disease but do not pose an immediate threat compared to elevated ammonia levels.
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