ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?
- A. Administer emergency medications without performing CPR
- B. Begin CPR
- C. Call the provider for a do-not-resuscitate (DNR) order
- D. Respect the client's wishes, and do not attempt CPR
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.
2. Which action should the nurse take to minimize the risk of medication errors?
- A. Prepare medications ahead of time to ensure they are ready.
- B. Ensure two nurses double-check medications before administration.
- C. Administer medications at the same time each day.
- D. Rely on memory to administer the correct medications.
Correct answer: B
Rationale: The correct answer is B because ensuring two nurses double-check medications before administration is a crucial step in minimizing the risk of medication errors. This practice helps in verifying the accuracy of medication orders and reducing the chances of mistakes. Choice A may not necessarily prevent errors as preparing medications ahead of time does not guarantee accuracy. Choice C, administering medications at the same time each day, is important for consistency but does not directly address the risk of errors. Choice D, relying on memory, is highly discouraged as it increases the likelihood of errors due to human forgetfulness.
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. When administering a subcutaneous injection of insulin to a client, what angle should the nurse use for the injection?
- A. 45-degree angle
- B. 60-degree angle
- C. 90-degree angle
- D. 30-degree angle
Correct answer: C
Rationale: The correct angle for administering a subcutaneous injection, such as insulin, is 90 degrees. This angle allows for the medication to be delivered into the subcutaneous layer of tissue beneath the skin. A 45-degree angle is typically used for administering subcutaneous injections in infants or those with reduced adipose tissue, while a 60-degree angle is commonly used for intramuscular injections. A 30-degree angle is not a standard angle for subcutaneous injections.
5. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?
- A. Administer the antibiotic immediately
- B. Obtain a sputum culture
- C. Notify the provider of the prescription
- D. Check the client's allergy history
Correct answer: B
Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.
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