ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A client with a DNR order has requested resuscitation during a visit from the family. What is the nurse's best course of action?
- A. Follow the family's request and perform CPR.
- B. Explain to the family that the DNR must be honored.
- C. Call the healthcare provider to cancel the DNR order.
- D. Delay resuscitation until further clarification can be made.
Correct answer: B
Rationale: The correct course of action for the nurse is to explain to the family that the DNR (Do Not Resuscitate) order must be honored. It is essential for the nurse to uphold the client's wishes as documented in the DNR order. Performing CPR against the client's expressed wishes in the DNR order would violate ethical and legal standards. Calling the healthcare provider to cancel the DNR order without the client's consent is inappropriate and goes against the client's autonomy. Delaying resuscitation can be detrimental in an emergency situation and may not align with the client's wishes as outlined in the DNR order.
2. While reviewing a client's chart, a nurse notices a discrepancy in the medication record. What should the nurse do?
- A. Correct the discrepancy and document the correction.
- B. Report the discrepancy to the nurse manager.
- C. Ignore the discrepancy assuming it is a clerical error.
- D. Discuss the discrepancy with the client and adjust the records.
Correct answer: B
Rationale: Reporting medication discrepancies to the nurse manager is crucial to ensure patient safety and proper follow-up. The nurse manager is responsible for addressing medication errors and implementing necessary corrective actions. Choice A is incorrect because simply correcting the discrepancy without reporting it may lead to potential harm to the patient and violates professional standards. Choice C is incorrect as ignoring the discrepancy increases the risk of medication errors going unresolved. Choice D is incorrect because discussing the discrepancy with the client before verifying the accuracy of the record can cause confusion and compromise patient safety.
3. What is the primary intervention for a client diagnosed with delirium?
- A. Provide a quiet and calm environment to minimize confusion
- B. Administer medication to reverse the symptoms of delirium
- C. Provide opportunities for social interaction to reduce isolation
- D. Encourage the client to remain physically active
Correct answer: A
Rationale: The correct answer is A: Provide a quiet and calm environment to minimize confusion. For clients diagnosed with delirium, creating a tranquil setting can help reduce agitation and disorientation. This intervention aims to decrease stimuli that may exacerbate symptoms. Administering medication (choice B) is not the primary intervention for delirium; it is usually reserved for specific underlying causes. While social interaction (choice C) and physical activity (choice D) are beneficial for overall well-being, they are not the primary interventions for managing delirium.
4. How can a healthcare professional help prevent pressure ulcers in an immobile patient?
- A. Ensuring proper nutrition and hydration
- B. Using moisture barriers to protect the skin
- C. Turning the patient every 2 hours to prevent pressure
- D. Providing special mattresses or padding
Correct answer: A
Rationale: Ensuring proper nutrition and hydration is crucial in preventing pressure ulcers in immobile patients. Adequate nutrition supports tissue health and repair, while hydration helps maintain skin elasticity. While turning the patient every 2 hours is important to prevent pressure injuries, it is not the primary way to address prevention. Using moisture barriers and providing special mattresses or padding are essential components of pressure ulcer prevention, but they are not as fundamental as ensuring proper nutrition and hydration.
5. 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.
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