ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is caring for a client who has dehydration. The client has a peripheral IV and a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?
- A. Teach the client to report findings of IV extravasation
- B. Evaluate the patency of the IV
- C. Consult with the pharmacist about the prescription
- D. Verify the prescription with the provider
Correct answer: D
Rationale: The nurse's priority action should be to verify the prescription with the provider. This is crucial to prevent injury from fluid volume overload and rapid potassium infusion. Verifying the prescription ensures that the correct solution, rate, and additives are ordered according to the client's condition. While evaluating the patency of the IV is important, verifying the prescription takes precedence to ensure patient safety. Consulting with the pharmacist can be beneficial, but confirming the prescription with the provider is the immediate priority. Teaching the client about IV extravasation is important but is not the first action the nurse should take in this scenario.
2. Protecting the rights and privacy of the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: C
Rationale: The correct answer is C: Implementation. Implementation is the phase where the nursing care plan is put into action, which includes safeguarding the patient's and their family's rights and privacy. Evaluation (choice A) involves reviewing the effectiveness of the care plan, Planning (choice B) is the phase where the care plan is developed, and Assessment (choice D) is the initial step where data about the patient is collected.
3. If a pair of monozygotic twins raised in the same environment end up being different from one another (e.g., interests, hobbies, etc.), it is highly likely due to:
- A. Cephalocaudal pattern
- B. Proximodistal pattern
- C. Cephamodistal pattern
- D. Gene-environment correlation
Correct answer: B
Rationale: The correct answer is B: Proximodistal pattern. Differences between monozygotic twins raised in the same environment are likely due to non-shared environmental influences, which lead to differences in interests, hobbies, and other individual characteristics. Choices A, C, and D are incorrect. Cephalocaudal pattern refers to the principle of development from head to toe, not relevant in explaining differences between twins. Cephamodistal pattern is not a recognized developmental term. Gene-environment correlation does not directly explain the differences between identical twins raised in the same environment.
4. One of the steps in coaching is often overlooked and taken for granted. What is this step?
- A. Stating the target
- B. Jumping to conclusions
- C. Asking for suggestions
- D. Tying the problem to clients' care
Correct answer: D
Rationale: In coaching, tying the problem to clients' care is crucial but often overlooked. This step ensures that the coach and the client focus on issues directly impacting the client's well-being. Stating the target (choice A) is important but not as critical as tying the problem to clients' care. Jumping to conclusions (choice B) is counterproductive in coaching as it may lead to incorrect assumptions. Asking for suggestions (choice C) is valuable, but it does not address the core aspect of linking the issue to the client's care, which is essential for effective coaching.
5. When administering an incorrect dose of medication, which facts related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct answer: A
Rationale: The nurse should document the time the medication was given in the client's medical record when administering an incorrect dose. This information is crucial for tracking the sequence of events leading to the error. Choice B, the client's response to the medication, is important for monitoring the client's condition post-administration but may not be directly linked to the incident report. Choice C, documenting the dose that was administered, is relevant but does not provide insights into the timing of events. Choice D, detailing the reason for the error, should be included in the incident report but may not need to be documented in the client's medical record.
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