ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A healthcare provider is assessing a client who has been using beclomethasone for 2 weeks to manage her asthma. What is the priority to report to the provider?
- A. Sore throat
- B. Cough
- C. Chest tightness
- D. Bronchospasms
Correct answer: D
Rationale: The correct answer is D: Bronchospasms. Bronchospasms can indicate worsening asthma and are considered a severe side effect that requires immediate attention. While sore throat, cough, and chest tightness are also possible side effects of beclomethasone, bronchospasms are of higher concern due to their association with significant respiratory distress and potential exacerbation of asthma symptoms.
2. Which intervention should be prioritized for a client experiencing panic-level anxiety?
- A. Postpone health teaching until anxiety subsides
- B. Encourage participation in group therapy
- C. Monitor vital signs every 5 minutes
- D. Provide reassurance and remain with the client
Correct answer: D
Rationale: During panic-level anxiety, the priority is to provide reassurance and remain with the client. This intervention helps to offer immediate support, comfort, and a sense of safety to the client. Postponing health teaching until anxiety subsides (Choice A) is not appropriate as the client's immediate emotional needs are more critical. Encouraging participation in group therapy (Choice B) may be beneficial in the long term but is not the priority during a panic attack. While monitoring vital signs (Choice C) is important, providing reassurance and support take precedence in managing panic-level anxiety.
3. A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Suggest that the client use a salt substitute
- B. Obtain a 12-lead ECG
- C. Obtain a blood sample for a serum sodium level
- D. Advise the client to add citrus juices and bananas to their diet
Correct answer: B
Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.
4. While providing care to a group of patients, which patient should the nurse see first?
- A. A patient after knee surgery who needs range of motion exercises
- B. A patient on bed rest who has renal calculi and needs to go to the bathroom
- C. A bedridden patient who has a reddened area on the buttocks who needs to be turned
- D. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
Correct answer: D
Rationale: The nurse should see the patient with a hip replacement experiencing chest pain and dyspnea first because these symptoms could indicate a pulmonary embolism, which is a life-threatening condition requiring immediate attention. The other patients also need care, but urgent assessment and intervention are crucial in the case of potential pulmonary embolism to prevent serious complications or death.
5. A nurse is discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?
- A. To donate organs, a client must provide consent prior to death
- B. The transplant team will harvest the organs for donation from the donor client
- C. During admission, all clients over the age of 18 should be asked about their organ donor status
- D. The National Organ Transplant Act prohibits the sale and purchase of organs
Correct answer: C
Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.
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