ATI RN
ATI Capstone Comprehensive Assessment B
1. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?
- A. Ensure the client is on seizure precautions.
- B. Educate the client about seizure triggers.
- C. Monitor for signs of an impending seizure.
- D. Initiate IV access for anti-seizure medication.
Correct answer: A
Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.
2. A nurse is providing teaching to the parent of a child who is receiving oral nystatin for oral candidiasis. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will mix the medication with applesauce
- B. I will provide a snack with the medication
- C. I will store the medication in the refrigerator
- D. I will swab the inside of my child's mouth with the medication
Correct answer: D
Rationale: The correct answer is D because swabbing the inside of the child's mouth with the nystatin solution is the correct administration method for treating oral candidiasis. Mixing the medication with applesauce or providing a snack with it is not the recommended method of administration. Storing the medication in the refrigerator is also unnecessary and not part of the proper administration instructions.
3. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?
- A. Encourage visitors during visiting hours.
- B. Keep the patient on fall precautions until discharge.
- C. Check on the patient every shift.
- D. Raise all four side rails.
Correct answer: B
Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.
4. A nurse is preparing medications for a client via nasogastric tube. What should the nurse do before administering the medications?
- A. Flush the tube with water and administer all medications at once
- B. Administer medications one after the other without flushing
- C. Crush all medications and mix them together for administration
- D. Administer medications in liquid form only
Correct answer: B
Rationale: Before administering medications through a nasogastric tube, the nurse should administer them one after the other without flushing. Flushing the tube with water should be done before and after each medication to prevent any interactions and ensure each medication is delivered effectively. The correct answer is not to administer all medications at once (choice A) as this can lead to potential drug interactions. Crushing all medications and mixing them together (choice C) is incorrect as each medication should be given separately to maintain their individual efficacy. Administering medications in liquid form only (choice D) is limiting and may not be suitable for all types of medications that need to be administered.
5. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?
- A. Wear a gown, gloves, face mask, and goggles for interactions with the patient.
- B. Transport the patient safely and quickly when going to the radiology department.
- C. Place the patient in a room with negative airflow.
- D. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.
Correct answer: D
Rationale: The correct answer is to use a dedicated blood pressure cuff that stays in the room and is used for that patient only. Patients on contact precautions require dedicated equipment to prevent the spread of disease. Using one blood pressure cuff exclusively for the patient on contact precautions helps minimize the risk of transmitting infections to other patients. Choices A, B, and C are incorrect because while wearing protective gear and isolating the patient in a room with negative airflow are important infection control measures, using dedicated equipment for the patient on contact precautions is specifically recommended to prevent the spread of disease in this scenario.
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