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 observes a colleague ignoring proper hand hygiene protocols. What should the nurse do first?
- A. Speak to the colleague directly.
- B. Ignore the situation, as it doesn't involve direct patient care.
- C. Report the colleague to the nursing manager.
- D. File an incident report immediately.
Correct answer: D
Rationale: The correct first action for the nurse to take in this situation is to file an incident report immediately. By doing so, the nurse ensures that the unsafe practice is documented for further investigation and corrective action. Speaking to the colleague directly may not address the root cause of the issue and could lead to potential conflicts. Ignoring the situation is not an appropriate response as it compromises patient safety. Reporting the colleague to the nursing manager should be done after filing an incident report to ensure that appropriate actions are taken to prevent future occurrences of non-compliance with hand hygiene protocols.
3. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?
- A. Aspirate for a blood return before depressing the plunger
- B. Insert the needle at a 45-degree angle
- C. Administer the medication 2.54 cm (1 in) from the umbilicus
- D. The nurse should not expel the air bubble in the prefilled syringe
Correct answer: D
Rationale: The correct action when administering enoxaparin is not to expel the air bubble in the prefilled syringe. Expelling the air bubble may lead to the loss of medication and result in an incomplete dose. Aspirating for a blood return (Choice A) is not necessary for subcutaneous injections like enoxaparin. Inserting the needle at a 45-degree angle (Choice B) is not specific to administering enoxaparin. Administering the medication 2.54 cm (1 in) from the umbilicus (Choice C) is not a standard guideline for enoxaparin administration.
4. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?
- A. Use sterile gloves during the procedure.
- B. Clean the catheter insertion site with alcohol.
- C. Insert the catheter as quickly as possible.
- D. Use a smaller catheter size to minimize trauma.
Correct answer: A
Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.
5. What is the primary focus of secondary prevention in community mental health care?
- A. Teaching stress-reduction techniques
- B. Early detection of mental illness
- C. Leading support groups for clients with substance use disorder
- D. Rehabilitation and prevention of further issues
Correct answer: B
Rationale: The correct answer is B: Early detection of mental illness. Secondary prevention in community mental health care focuses on identifying mental health issues at an early stage to provide timely interventions. Choice A, teaching stress-reduction techniques, is more aligned with primary prevention aimed at preventing the onset of mental health problems. Choice C, leading support groups for clients with substance use disorder, pertains more to providing specific interventions for individuals with substance use issues rather than the general focus of secondary prevention. Choice D, rehabilitation and prevention of further issues, is more related to tertiary prevention, which involves addressing existing mental health conditions and preventing complications or recurrence.
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