ATI RN
ATI Capstone Comprehensive Assessment B
1. 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.
2. The clinic nurse is teaching parents about physiologic anemia that occurs in infants. What statement should the nurse include about the cause of physiologic anemia?
- A. Maternally derived iron stores are depleted in the first 2 months.
- B. Fetal hemoglobin results in a shortened survival of red blood cells.
- C. The production of adult hemoglobin decreases in the first year of life.
- D. Low levels of fetal hemoglobin depress the production of erythropoietin.
Correct answer: B
Rationale: Physiologic anemia is caused by the transition from fetal to adult hemoglobin, with fetal hemoglobin having a shorter lifespan, leading to a temporary decrease in red blood cells.
3. A nurse is reviewing the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse expect to include?
- A. Encourage group activities to promote socialization.
- B. Encourage the client to take frequent naps throughout the day.
- C. Provide the client with frequent high-calorie snacks.
- D. Promote physical activity during mealtimes to stimulate appetite.
Correct answer: C
Rationale: Providing high-calorie snacks is essential when caring for a client in the manic phase of bipolar disorder because they often have increased energy expenditure and may not eat adequately due to their heightened activity levels. Encouraging group activities (Choice A) may overwhelm the client further during this phase. Encouraging frequent naps (Choice B) contradicts the need to manage increased energy levels. Promoting physical activity during mealtimes (Choice D) may not be appropriate as it can distract the client from eating, which is crucial in meeting their nutritional needs.
4. A client with neutropenia is admitted to the hospital. What precaution is most important for the nurse to implement?
- A. Strict hand hygiene.
- B. Limit visitor contact with the client.
- C. Administer prophylactic antibiotics as ordered.
- D. Administer blood products as ordered.
Correct answer: A
Rationale: The correct answer is A: Strict hand hygiene. Neutropenic clients have a low level of neutrophils, which are important in fighting infections. Therefore, maintaining strict hand hygiene is crucial in preventing the introduction of pathogens that could lead to infections. Limiting visitor contact (choice B) is important but not as critical as preventing the introduction of pathogens through proper hand hygiene. Administering prophylactic antibiotics (choice C) and blood products (choice D) are treatment measures and do not address the preventive aspect that hand hygiene provides.
5. An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation?
- A. Water excess
- B. Sodium excess
- C. Water depletion
- D. Potassium excess
Correct answer: C
Rationale: These symptoms are indicative of dehydration or water depletion, which is common in infants and can rapidly lead to severe consequences if not addressed promptly.
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