ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?
- A. Amphotericin B
- B. Amoxicillin-clavulanate
- C. Erythromycin
- D. Gentamicin
Correct answer: B
Rationale: Amoxicillin-clavulanate is related to penicillin, and a cross-sensitivity could occur, so the provider should be consulted.
2. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?
- A. Report any sign of infection to the provider immediately
- B. Expect your blood pressure to increase
- C. Easy bruising may occur while taking this medication
- D. Muscle rigidity is an expected adverse effect during the first few days of therapy
Correct answer: A
Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.
3. A nurse is preparing a client for surgery. Which of the following actions should be taken first?
- A. Ensure informed consent is signed
- B. Start IV fluids
- C. Administer preoperative antibiotics
- D. Reinforce surgical site dressing
Correct answer: A
Rationale: The correct answer is to ensure informed consent is signed first when preparing a client for surgery. This step is crucial as it ensures that the client has been informed about the procedure, risks, benefits, and alternatives before giving consent. Starting IV fluids (choice B) may be necessary but comes after obtaining informed consent. Administering preoperative antibiotics (choice C) is important but typically follows confirming informed consent. Reinforcing surgical site dressing (choice D) is a postoperative step and does not take precedence over obtaining informed consent.
4. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?
- A. Apply a dry, sterile dressing to the wound.
- B. Use sterile saline to clean the wound.
- C. Apply a warm compress to promote circulation.
- D. Keep the wound open to air for faster healing.
Correct answer: B
Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.
5. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?
- A. Measure and document the urine in the drainage bag
- B. Remove the tape or device securing the catheter to the client's thigh
- C. Position the client supine
- D. Deflate the catheter balloon using a sterile syringe
Correct answer: A
Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.
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