ATI RN
ATI Capstone Comprehensive Assessment B
1. A client with a history of falls is being admitted to the unit. What intervention should the nurse implement first?
- A. Increase the client's medication to ensure they don't fall.
- B. Use bed alarms to monitor the client's movements.
- C. Encourage the client to use a walker for mobility.
- D. Assign the client to a nursing assistant for supervision.
Correct answer: B
Rationale: The correct answer is B: 'Use bed alarms to monitor the client's movements.' When a client with a history of falls is admitted, the nurse's initial intervention should focus on fall prevention measures. Using bed alarms to monitor the client's movements can help alert the healthcare team if the client attempts to get out of bed and reduce the risk of falls. Choice A is incorrect because increasing medication should not be the first intervention as it may not address the underlying causes of falls and can have adverse effects. Choice C may be appropriate but is not the priority over implementing safety measures like bed alarms. Choice D is incorrect as assigning the client to a nursing assistant for supervision alone may not be as effective as utilizing bed alarms for continuous monitoring.
2. The client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?
- A. Fast for 8 hours before the test
- B. Eat a regular supper and breakfast
- C. Continue to take all oral medications as scheduled.
- D. Monitor own bowel movement pattern for constipation
Correct answer: A
Rationale: Fasting for 8 hours ensures that the stomach is empty, which is necessary for an accurate barium swallow test.
3. Myxedema coma is a life-threatening complication of long-standing and untreated hypothyroidism with one of the following characteristics.
- A. Hyperglycemia
- B. Hypothermia
- C. Hyperthermia
- D. Hypoglycemia
Correct answer: A
Rationale: Myxedema coma is associated with hypothermia, not hyperthermia. Therefore, the correct characteristic of myxedema coma is hypothermia. This condition is a medical emergency that requires prompt recognition and intervention to prevent serious complications. The presence of hyperglycemia is not a defining characteristic of myxedema coma, making choice A the correct answer in this case. Hyperthermia and hypoglycemia are not typically seen in myxedema coma and are not consistent with the clinical presentation of this condition.
4. What is the priority nursing intervention for a patient with a new tracheostomy?
- A. Suction the tracheostomy as needed to maintain a patent airway.
- B. Monitor the patient's oxygen saturation.
- C. Provide humidified air to prevent drying of the airway.
- D. Administer pain medication as prescribed.
Correct answer: A
Rationale: The correct answer is to suction the tracheostomy as needed to maintain a patent airway. After a tracheostomy procedure, the immediate concern is airway patency to prevent respiratory compromise. Suctioning helps clear secretions and maintains a clear airway, reducing the risk of respiratory distress. Monitoring the patient's oxygen saturation (choice B) is important but not the priority compared to ensuring a clear airway. Providing humidified air (choice C) and administering pain medication (choice D) are also essential aspects of care for a patient with a tracheostomy, but they are not the priority when immediate airway management is required.
5. A client with a history of alcohol use disorder is admitted to the hospital for detoxification. Which of the following symptoms should the nurse expect to observe during withdrawal? Select one that doesn't apply.
- A. Tremors
- B. Hallucinations
- C. Diaphoresis
- D. Bradycardia
Correct answer: D
Rationale: During alcohol withdrawal, symptoms such as tremors, hallucinations, diaphoresis, and seizures are commonly observed. Bradycardia is not typically associated with alcohol withdrawal; instead, tachycardia, an increased heart rate, is more commonly seen. Therefore, bradycardia is the correct answer as it is not an expected symptom during alcohol withdrawal. Tremors, hallucinations, and diaphoresis are all common manifestations of alcohol withdrawal, while bradycardia is not typically seen in this context.
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