ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client. What is the nurse's responsibility?
- A. Contact the stoma nurse immediately.
- B. Educate the client on stoma care.
- C. Assess the stoma site for complications.
- D. Arrange for follow-up visits with the stoma nurse.
Correct answer: B
Rationale: The correct answer is B: 'Educate the client on stoma care.' The nurse's primary responsibility in this scenario is to provide education to the client on stoma care. This empowers the client to take care of their colostomy effectively. While it is important to involve the stoma nurse for specialized care, the immediate action required from the nurse is client education. Choice A is incorrect as the immediate action is not to contact the stoma nurse but to educate the client first. Choice C is not the nurse's initial responsibility unless there are obvious complications. Choice D is premature as arranging follow-up visits should come after the client has been educated and initial care has been provided.
2. A healthcare provider is assessing a client who has carpal tunnel syndrome. The provider should expect which of the following findings?
- A. Positive Chvostek's sign
- B. Cool extremities
- C. Positive Phalen's sign
- D. Decreased radial pulse
Correct answer: C
Rationale: Phalen's sign is often positive in clients with carpal tunnel syndrome due to nerve compression. Chvostek's sign (Choice A) is related to hypocalcemia, cool extremities (Choice B) are not typically associated with carpal tunnel syndrome, and decreased radial pulse (Choice D) is not a common finding in carpal tunnel syndrome.
3. A healthcare provider writes a medication order that seems excessively high for the patient's condition. What is the nurse's first step?
- A. Administer the medication immediately.
- B. Hold the medication and consult the provider.
- C. Reduce the dose without consulting the provider.
- D. Administer the medication after double-checking with another nurse.
Correct answer: B
Rationale: The correct first step for the nurse when encountering a medication order that appears excessively high for the patient's condition is to hold the medication and consult the provider. Administering the medication immediately (Choice A) without clarification could pose a risk to the patient's safety. Reducing the dose without consulting the provider (Choice C) is not recommended as it may lead to suboptimal treatment. Administering the medication after double-checking with another nurse (Choice D) is not sufficient; consulting the provider directly is crucial to ensure the accuracy and safety of the medication order.
4. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?
- A. Redness and swelling are normal after surgery
- B. Any drainage from the incision site is not concerning
- C. Yellow drainage is normal
- D. I should monitor for increased redness or warmth
Correct answer: B
Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.
5. A nurse manager is discussing electronic medical records with a newly licensed nurse. Which of the following actions should the nurse take to maintain client confidentiality?
- A. Log out of the computer terminal before leaving.
- B. Share passwords for computer access with colleagues.
- C. Change computer access passwords on a regular basis.
- D. Avoid accessing information about clients admitted to other units.
Correct answer: A
Rationale: The correct answer is A: Log out of the computer terminal before leaving. Logging out before leaving the computer terminal is crucial to ensuring patient data remains confidential and to prevent unauthorized access. Choice B is incorrect because sharing passwords compromises confidentiality. Choice C is incorrect as changing passwords regularly, although a good practice for security, is not directly related to maintaining client confidentiality. Choice D is incorrect as it does not address the immediate concern of maintaining client confidentiality through proper access to electronic medical records.
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