ATI RN
ATI Capstone Comprehensive Assessment B
1. A healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?
- A. Fever of 101°F.
- B. Blood pressure of 140/90 mmHg.
- C. Heart rate of 95 beats per minute.
- D. Crackles heard in the lung bases.
Correct answer: D
Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.
2. A nurse caring for a client under airborne precautions notes that the client is scheduled for a nuclear scan. What is the appropriate action for the nurse to take?
- A. Planning to have the nuclear scan performed at the bedside
- B. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued
- C. Asking the technicians in the nuclear scan department to wear masks
- D. Placing a surgical mask on the client for transport and for contact with other individuals
Correct answer: D
Rationale: The correct action for the nurse is to place a surgical mask on the client for transport and for contact with other individuals when a patient under airborne precautions requires movement. This helps prevent the spread of infectious agents. Planning to have the nuclear scan at the bedside (Choice A) may not be feasible or appropriate. Calling the nuclear medicine department to delay the test (Choice B) may inconvenience the client and disrupt the scheduled procedure. Asking technicians in the nuclear scan department to wear masks (Choice C) does not provide adequate protection for others who may come into contact with the client outside the department.
3. Which nursing action will best help a patient with diabetes manage their condition?
- A. Monitor the patient's blood sugar levels regularly.
- B. Encourage the patient to follow a diabetic meal plan.
- C. Teach the patient how to administer insulin.
- D. Teach the patient about the complications of diabetes.
Correct answer: C
Rationale: The correct answer is C: Teach the patient how to administer insulin. This action is crucial in promoting self-management and control of diabetes. By educating the patient on administering insulin, they can actively participate in their treatment plan. Monitoring blood sugar levels (choice A) is important but doesn't empower the patient to take direct action. Encouraging a diabetic meal plan (choice B) is beneficial but may not directly address the need for insulin administration. Teaching about the complications of diabetes (choice D) is essential but may not be as immediately impactful as teaching insulin administration for day-to-day management.
4. A patient is being treated for dehydration. Which lab result would support the diagnosis?
- A. Elevated hemoglobin
- B. Low sodium level
- C. High white blood cell count
- D. Elevated BUN
Correct answer: D
Rationale: Elevated BUN levels are a characteristic finding in dehydration due to reduced kidney perfusion and increased reabsorption of urea. Hemoglobin levels might be elevated in conditions like polycythemia vera, not directly related to dehydration. A low sodium level could be seen in conditions like hyponatremia. A high white blood cell count is more indicative of infection or inflammation rather than dehydration.
5. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?
- A. Provide assistance to the bathroom
- B. Insert a straight catheter
- C. Increase fluids
- D. Perform a bladder scan
Correct answer: D
Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.
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