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. A nurse is preparing to administer ampicillin 500 mg IV bolus every 6 hours. Available is ampicillin 500 mg in 50 mL dextrose 5% in water (D5W) to infuse over 20 minutes. The nurse should set the IV pump to deliver how many mL/hr?
- A. 100 mL/hr
- B. 150 mL/hr
- C. 200 mL/hr
- D. 250 mL/hr
Correct answer: B
Rationale: To infuse 50 mL over 20 minutes, the pump should be set to 150 mL/hr. This calculation ensures the correct rate for the infusion of the medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the given information.
3. A patient requires assistance to stand from a sitting position. Which action by the nurse ensures patient safety?
- A. Allow the patient to pull up on the nurse's arm.
- B. Place a gait belt around the patient for support.
- C. Have the patient push off the chair with their hands.
- D. Ask the patient to lift themselves up without support.
Correct answer: B
Rationale: The correct answer is B. Placing a gait belt around the patient for support is the safest option when assisting a patient to stand from a sitting position. This belt provides stability and support, reducing the risk of falls or injuries during the transfer. Choices A, C, and D are incorrect. Allowing the patient to pull up on the nurse's arm (Choice A) may lead to instability and compromise safety. Having the patient push off the chair with their hands (Choice C) might not provide sufficient support, especially for patients who require assistance. Asking the patient to lift themselves up without support (Choice D) can be dangerous and increase the risk of falls.
4. A nurse is assessing the skin of an immobilized patient. What will the nurse do?
- A. Use a standardized tool such as the Braden Scale.
- B. Limit the amount of fluid intake.
- C. Have special times for inspection so as not to interrupt routine care.
- D. Assess the skin every 4 hours.
Correct answer: A
Rationale: The correct answer is A. When assessing the skin of an immobilized patient, it is essential to use a standardized tool such as the Braden Scale to identify patients at high risk for impaired skin integrity. This tool helps in early identification and appropriate intervention. Choice B, limiting fluid intake, is not directly related to skin assessment. Choice C, having special times for inspection, may not ensure timely identification of skin issues. Choice D, assessing the skin every 4 hours, lacks specificity regarding the use of a validated tool for risk assessment.
5. A client with hypertension is prescribed atenolol. Which of the following findings should the nurse include as adverse effects of this medication?
- A. Cough
- B. Tremor
- C. Constipation
- D. Bradycardia
Correct answer: D
Rationale: Correct. Bradycardia is a known adverse effect of atenolol, a beta-blocker medication commonly used to treat hypertension. Atenolol can slow down the heart rate, leading to bradycardia. The nurse should monitor the client for signs of bradycardia, such as dizziness, fatigue, or fainting. Choices A, B, and C are incorrect because cough, tremor, and constipation are not typically associated with atenolol use.
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