ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. 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.
2. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?
- A. Report any sign of infection to the provider immediately
- B. Expect your blood pressure to increase
- C. Easy bruising may occur while taking this medication
- D. Muscle rigidity is an expected adverse effect during the first few days of therapy
Correct answer: A
Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.
3. A client expresses concern about hair loss during chemotherapy. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy begins.
- B. Offer resources for wigs and head coverings.
- C. Assure the client that hair loss will be minimal.
- D. Ignore the client's concerns about hair loss.
Correct answer: B
Rationale: During chemotherapy, hair loss is a common side effect. Offering resources for wigs and head coverings can help the client cope with this change in appearance, maintain self-esteem, and feel more comfortable during the process. Encouraging the client to cut their hair short does not address the emotional impact of hair loss and may not be the client's preference. Assuring the client that hair loss will be minimal may provide false hope as significant hair loss is a common occurrence. Ignoring the client's concerns is not appropriate and goes against the principles of providing holistic and compassionate care.
4. A client complains of pain in the leg while in skeletal traction. What is the nurse's priority action?
- A. Increase the pain medication immediately
- B. Check for signs of infection
- C. Reposition the client's leg for comfort
- D. Notify the physician of the client's complaints
Correct answer: B
Rationale: The correct answer is B: Check for signs of infection. In skeletal traction, the priority action for the nurse when a client complains of pain in the leg is to first assess for signs of infection. Pain in skeletal traction can be a symptom of infection or other complications, so checking for signs of infection is crucial before considering other interventions. Increasing pain medication immediately (Choice A) may mask the symptoms of an underlying infection. Repositioning the client's leg for comfort (Choice C) may provide temporary relief but does not address the potential underlying issue. Notifying the physician of the client's complaints (Choice D) is important but assessing for infection should come first to ensure timely and appropriate intervention.
5. A nurse is providing teaching to a parent of a child with celiac disease. Which food choice should the nurse include?
- A. Rice
- B. Barley
- C. Wheat
- D. Rye
Correct answer: A
Rationale: The correct answer is A, Rice. In celiac disease, individuals must avoid gluten-containing foods. Rice is a safe option as it is gluten-free. Barley (choice B), Wheat (choice C), and Rye (choice D) all contain gluten and should be avoided in a celiac diet. Therefore, the nurse should emphasize including rice in the child's diet.
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