ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse caring for a client under airborne precautions notes that the client is scheduled for a nuclear scan. What is the appropriate action for the nurse to take?
- A. Planning to have the nuclear scan performed at the bedside
- B. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued
- C. Asking the technicians in the nuclear scan department to wear masks
- D. Placing a surgical mask on the client for transport and for contact with other individuals
Correct answer: D
Rationale: The correct action for the nurse is to place a surgical mask on the client for transport and for contact with other individuals when a patient under airborne precautions requires movement. This helps prevent the spread of infectious agents. Planning to have the nuclear scan at the bedside (Choice A) may not be feasible or appropriate. Calling the nuclear medicine department to delay the test (Choice B) may inconvenience the client and disrupt the scheduled procedure. Asking technicians in the nuclear scan department to wear masks (Choice C) does not provide adequate protection for others who may come into contact with the client outside the department.
2. A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?
- A. Assess for pain relief.
- B. Monitor for respiratory depression.
- C. Assess the infusion site for complications.
- D. Increase the dosage if the client reports more pain.
Correct answer: B
Rationale: Correct answer: Before administering morphine sulfate, the nurse should monitor for respiratory depression as it is a significant side effect of this medication. Assessing for pain relief (Choice A) is important but not a pre-administration assessment. Checking the infusion site for complications (Choice C) is relevant for IV medications, not specifically for morphine sulfate. Increasing the dosage if the client reports more pain (Choice D) is not appropriate without further assessment and medical orders.
3. A case manager at an assisted living facility is reviewing the use of complementary health practices by several clients. Which of the following actions should the case manager plan to take?
- A. Plan to report a client's use of echinacea to the provider as a contraindication to aspirin therapy
- B. Plan to schedule time for a new client to continue tai chi practice as a stress reduction technique
- C. Tell a client that yoga has not been proven effective to reduce manifestations of menopause
- D. Tell a client who drinks cranberry juice daily that it can help treat existing urinary tract infections
Correct answer: B
Rationale: The correct answer is B. Tai chi is a recognized complementary health practice for stress reduction. Scheduling time for a new client to continue tai chi practice aligns with supporting holistic care. Choice A is incorrect because reporting a client's use of echinacea as a contraindication to aspirin therapy is not necessary without further context or evidence of interactions. Choice C is wrong because yoga can indeed be effective in reducing manifestations of menopause. Choice D is also incorrect because while cranberry juice is known to help prevent urinary tract infections, it is not typically used to treat existing infections.
4. What intervention should the nurse implement for a patient receiving a blood transfusion?
- A. Administer antihistamines to prevent allergic reactions.
- B. Monitor the patient for signs of circulatory overload.
- C. Ensure the blood transfusion is completed within 4 hours.
- D. Check the patient's vital signs every 30 minutes during the transfusion.
Correct answer: B
Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.
5. While working the night shift, a nurse observes a colleague behaving strangely. What is the best course of action?
- A. Ignore the behavior and continue working
- B. Report the behavior to the supervisor
- C. Ask the colleague if everything is okay
- D. Discuss the behavior with other colleagues
Correct answer: B
Rationale: When a nurse observes a colleague behaving strangely, the best course of action is to report the behavior to the supervisor. Unusual behavior by a healthcare professional could compromise patient safety and should be addressed promptly. Ignoring the behavior (Choice A) could potentially lead to negative outcomes for patients. Asking the colleague directly (Choice C) may not be appropriate if the behavior poses a risk. Discussing the behavior with other colleagues (Choice D) may not directly address the issue and could lead to gossip rather than a resolution.
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