ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A client had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?
- A. Maintain foam wedge between legs
- B. Monitor for shortening of the affected leg
- C. Encourage use of elastic stockings
- D. Avoid flexing the hips more than 60 degrees
Correct answer: A
Rationale: The correct answer is to maintain a foam wedge between the legs. This intervention helps prevent hip dislocation by maintaining proper leg alignment after surgery. Monitoring for shortening of the affected leg (choice B) is not directly related to preventing dislocation. Encouraging the use of elastic stockings (choice C) is more related to preventing deep vein thrombosis rather than dislocation. Avoiding flexing the hips more than 60 degrees (choice D) is important post-surgery, but it is not the most direct intervention to prevent dislocation.
2. Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium. The nutrition instructions should include:
- A. Recommend protein of high biologic value like eggs, poultry and lean meats
- B. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes
- C. Allowing the client cheese, canned foods and other processed food
- D. Bananas, cantaloupe, orange and other fresh fruits can be included in the diet
Correct answer: B
Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.
3. A parent asks the nurse what would be the first indication that acute glomerulonephritis was improving. What would be the nurse's best response?
- A. Blood pressure will stabilize.
- B. Your child will have more energy.
- C. Urine will be free of protein.
- D. Urine output will increase.
Correct answer: D
Rationale: Increased urine output is often the first sign that acute glomerulonephritis is improving, as it indicates a reduction in fluid retention and better kidney function. Stabilization of blood pressure and other symptoms typically follow.
4. A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital for pneumonia. Which intervention should the nurse prioritize?
- A. Administer bronchodilators as prescribed.
- B. Monitor oxygen saturation levels continuously.
- C. Administer intravenous antibiotics as prescribed.
- D. Provide respiratory therapy treatments as needed.
Correct answer: C
Rationale: Administering IV antibiotics is crucial for treating pneumonia in a client with COPD. Pneumonia is an infection of the lungs that requires prompt antibiotic therapy to prevent complications and improve outcomes. While bronchodilators may help with COPD symptoms, in the case of pneumonia, addressing the infection is the priority. Continuous monitoring of oxygen saturation is important, but administering antibiotics to treat the underlying infection takes precedence. Respiratory therapy treatments can be beneficial, but they are not the initial priority when managing pneumonia in a client with COPD.
5. Nurse Maria is preparing a care plan for a client receiving external radiation therapy. Which of the following interventions should be included?
- A. Use heating pads on the treated area
- B. Wear loose, soft clothing over the treated area
- C. Expose the treated area to sunlight
- D. Apply ice packs to the treated area
Correct answer: B
Rationale: Radiation therapy can cause skin irritation, dryness, and sensitivity in the treated area. Wearing loose, soft clothing helps minimize friction and pressure on the skin, reducing irritation and promoting comfort. The skin in the treated area is often more sensitive and vulnerable to damage, so this intervention helps protect the skin while maintaining the client’s comfort during the course of treatment.
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