ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?
- A. Drowsy but responsive when her name is called
- B. SaO2 94%
- C. Respiratory rate 8/min
- D. Pain level of 6 on a scale from 0 to 10
Correct answer: C
Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.
2. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?
- A. Encourage the patient to perform incentive spirometry.
- B. Assist the patient in ambulating around the unit.
- C. Reposition the patient every 2 hours.
- D. Administer pain medication as prescribed.
Correct answer: A
Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.
3. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?
- A. Wear a gown, gloves, face mask, and goggles for interactions with the patient.
- B. Transport the patient safely and quickly when going to the radiology department.
- C. Place the patient in a room with negative airflow.
- D. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.
Correct answer: D
Rationale: The correct answer is to use a dedicated blood pressure cuff that stays in the room and is used for that patient only. Patients on contact precautions require dedicated equipment to prevent the spread of disease. Using one blood pressure cuff exclusively for the patient on contact precautions helps minimize the risk of transmitting infections to other patients. Choices A, B, and C are incorrect because while wearing protective gear and isolating the patient in a room with negative airflow are important infection control measures, using dedicated equipment for the patient on contact precautions is specifically recommended to prevent the spread of disease in this scenario.
4. Which of the following is the correct method to reduce the risk of infection when handling a urinary catheter?
- A. Clean the catheter tubing with soap and water.
- B. Maintain sterile technique when inserting the catheter.
- C. Insert the catheter using clean gloves and a clean technique.
- D. Flush the catheter tubing regularly with sterile water.
Correct answer: B
Rationale: The correct method to reduce the risk of infection when handling a urinary catheter is to maintain sterile technique when inserting the catheter. Sterile technique helps prevent introducing pathogens into the urinary system, reducing the risk of infection. Choice A is incorrect because cleaning the catheter tubing with soap and water is not sufficient for preventing infection. Choice C is incorrect as clean gloves and technique are not enough; sterile technique is necessary. Choice D is incorrect as flushing the catheter tubing with sterile water, though important for maintaining catheter patency, does not address the need for sterile technique during insertion to prevent infection.
5. A healthcare professional is reviewing the medical record of a client who received their medications 1 hour ago. The client reports chest pain. This can be an adverse effect of what medication?
- A. Digoxin
- B. Albuterol
- C. Lisinopril
- D. Metoprolol
Correct answer: B
Rationale: The correct answer is B, Albuterol. Albuterol can cause chest pain as a side effect due to its beta-agonist effects, which can lead to chest discomfort. Digoxin (choice A) is not typically associated with causing chest pain. Lisinopril (choice C) and Metoprolol (choice D) are not known to commonly cause chest pain as a side effect.
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