ATI RN
ATI Capstone Comprehensive Assessment B
1. If a nurse is uncomfortable documenting a verbal prescription, what should the nurse do?
- A. Document the prescription without seeking clarification.
- B. Clarify the verbal prescription with the healthcare provider.
- C. Refuse to document the prescription.
- D. Speak with the client's family to clarify the situation.
Correct answer: B
Rationale: When a nurse is uncomfortable documenting a verbal prescription, the best course of action is to clarify the prescription with the healthcare provider. This is crucial to ensure that the information is accurate and to provide safe and appropriate care. Option A is incorrect because blindly documenting without seeking clarification can lead to errors. Option C is incorrect as refusing to document the prescription altogether is not in the best interest of the patient. Option D is also incorrect as speaking with the client's family is not the appropriate step to clarify a verbal prescription; the healthcare provider should be the primary source for this clarification.
2. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?
- A. Decrease the client's IV fluids
- B. Reposition the client
- C. Administer oxygen by face mask
- D. Document the findings
Correct answer: C
Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.
3. A nurse at a provider's office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (SATA)
- A. Top fruits with yogurt
- B. Add cream to soups
- C. Increase fluids during meals
- D. Use milk instead of water in recipes
Correct answer: A
Rationale: Topping fruits with yogurt is the correct recommendation to increase calorie and protein intake for a client on chemotherapy who is losing weight. Yogurt is a good source of protein and adding it to fruits can provide additional calories as well. Choice B, adding cream to soups, may increase calorie intake but does not specifically address protein needs. Choice C, increasing fluids during meals, is important for hydration but does not directly address calorie and protein intake. Choice D, using milk instead of water in recipes, may increase calorie content but does not focus on increasing protein intake, which is essential for clients on chemotherapy.
4. A client is undergoing chemotherapy and expresses concern about hair loss. What is the best response?
- A. Reassure the client that hair loss is not permanent.
- B. Provide resources for wigs or hairpieces.
- C. Encourage the client to cut their hair short in advance.
- D. Advise the client that chemotherapy causes temporary hair loss.
Correct answer: D
Rationale: The best response when a client undergoing chemotherapy expresses concern about hair loss is to advise them that chemotherapy causes temporary hair loss. This response provides accurate information to the client about the side effect they are experiencing. Choice A is incorrect because it may provide false reassurance as for some individuals, hair loss can be a challenging experience. Choice B is not the best initial response as addressing the client's concerns and providing information should come first. Choice C is not the most appropriate response as cutting hair short may not necessarily prevent hair loss and does not address the client's concerns about the temporary nature of chemotherapy-induced hair loss.
5. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?
- A. Patient is lying semiprone.
- B. Patient is lying on side.
- C. Patient is lying on abdomen.
- D. Patient is lying on back.
Correct answer: B
Rationale: The correct answer is B because the lateral position means lying on the side with body weight on the dependent hip and shoulder. Choice A is incorrect as 'semiprone' means lying on the abdomen with one leg flexed. Choice C is incorrect as 'prone' means lying face down. Choice D is incorrect as 'supine' means lying on the back.
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