ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A health care provider asks the nurse to administer a medication with a dosage significantly higher than usual. What is the nurse's first action?
- A. Administer the medication as ordered.
- B. Question the provider and verify the dose.
- C. Administer half the dosage as a precaution.
- D. Refuse to administer the medication without clarification.
Correct answer: B
Rationale: When a health care provider orders a medication with a dosage significantly higher than usual, the nurse's initial action should be to question the provider and verify the dose. This is crucial to ensure patient safety and prevent medication errors. Administering the medication as ordered (Choice A) without clarification could potentially harm the patient if there was an error in the prescription. Administering half the dosage as a precaution (Choice C) is not a safe practice as it deviates from the prescribed order. Refusing to administer the medication without clarification (Choice D) is important, but the first step should be to seek clarification from the provider to prevent any unnecessary delays in patient care.
2. During a seizure, what is the primary intervention?
- A. Protect the patient from injury
- B. Insert an airway
- C. Elevate the head of the bed
- D. Withdraw all pain medications
Correct answer: A
Rationale: The primary intervention during a seizure is to protect the patient from injury. This involves creating a safe environment by moving harmful objects away, cushioning the head, and staying with the patient until the seizure ends. Inserting an airway is only necessary if the patient's airway is obstructed, not routinely during a seizure. Elevating the head of the bed is not a priority during an active seizure as it won't affect the seizure's outcome. Withdrawing all pain medications is not a standard practice unless there are specific contraindications related to the seizure itself.
3. Which is the priority nursing assessment when providing care for an infant at risk for dehydration?
- A. Urine output
- B. Urine specific gravity
- C. Vital signs
- D. Daily weight
Correct answer: D
Rationale: The correct answer is Daily weight. Daily weight is a crucial assessment in infants at risk for dehydration because changes in weight can indicate fluid balance and dehydration status. It is essential to monitor daily weight to promptly identify and manage dehydration in infants.
4. A client is taking Sucralfate PO for Peptic Ulcer Disease and has a new prescription for phenytoin to control seizures. Which of the following instructions should the nurse include?
- A. Take an antacid with the sucralfate.
- B. Take sucralfate with a glass of milk.
- C. Allow a 2-hour interval between these medications.
- D. Chew the sucralfate thoroughly before swallowing.
Correct answer: C
Rationale: Sucralfate can interfere with the absorption of phenytoin. To prevent this interaction, the client should allow a 2-hour interval between taking sucralfate and phenytoin. This timing helps to ensure adequate absorption and effectiveness of both medications without compromising therapeutic outcomes. Choices A, B, and D are incorrect because taking an antacid with sucralfate, taking sucralfate with a glass of milk, and chewing sucralfate thoroughly before swallowing do not address the need for a 2-hour interval between these medications to prevent interference with phenytoin absorption.
5. What is the best method to identify which type of stroke the client has?
- A. Obtain a 12-lead electrocardiogram STAT
- B. Obtain a blood specimen for electrolytes and blood cultures
- C. Ask the client about current allergies
- D. Obtain a cranial computerized tomogram (CT) STAT
Correct answer: D
Rationale: The correct answer is to obtain a cranial computerized tomogram (CT) STAT. A cranial CT scan is the best method to quickly identify the type of stroke a client is experiencing. Options A, B, and C are not appropriate for identifying the type of stroke as they are not specific to assessing stroke types.
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