ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?
- A. Increase protein intake
- B. Monitor blood glucose levels frequently
- C. Increase the dose of insulin
- D. Reduce carbohydrate intake
Correct answer: B
Rationale: The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.
2. A patient with chronic kidney disease has been prescribed a low-protein diet. What is the nurse's priority intervention?
- A. Encourage the patient to eat small, frequent meals.
- B. Monitor the patient's intake and output.
- C. Educate the patient on the benefits of a low-protein diet.
- D. Monitor the patient's protein intake closely.
Correct answer: D
Rationale: The correct answer is to monitor the patient's protein intake closely. In patients with chronic kidney disease on a low-protein diet, monitoring protein intake is crucial to prevent complications such as malnutrition or inadequate nutrient intake. Encouraging small, frequent meals (Choice A) can be beneficial but is not the priority over monitoring protein intake. Monitoring intake and output (Choice B) is important but does not directly address the specific focus on protein intake. Educating the patient on the benefits of a low-protein diet (Choice C) is essential but not as immediate as monitoring the actual protein intake.
3. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?
- A. Loud volume of the television set
- B. Wall-to-wall carpet in the living room
- C. Low chairs without armrests
- D. Use of indirect lighting
Correct answer: C
Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.
4. What are the important considerations when administering blood products to a patient?
- A. Ensuring proper documentation of the transfusion
- B. Verifying the patient's identity before administration
- C. Monitoring for allergic reactions or transfusion reactions
- D. Monitoring the patient's vital signs during transfusion
Correct answer: B
Rationale: Verifying the patient's identity before administration is a critical step to ensure that the correct blood product is given to the right patient, thereby preventing transfusion errors. While ensuring proper documentation of the transfusion (choice A) is important for record-keeping, verifying patient identity (choice B) directly addresses the risk of administering blood to the wrong patient. Monitoring for allergic reactions or transfusion reactions (choice C) and monitoring the patient's vital signs during transfusion (choice D) are also essential considerations during blood product administration, but verifying patient identity takes precedence to prevent potentially life-threatening errors.
5. What is the most important action for the nurse to take before administering digoxin to a patient?
- A. Check the patient's heart rate before administration.
- B. Assess the patient's blood pressure before administration.
- C. Ensure the patient has eaten before administration.
- D. Monitor the patient's weight before administration.
Correct answer: A
Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.
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