ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
- A. Wear gloves only
- B. Wear a mask
- C. Wash hands before and after client care
- D. Use an N95 respirator
Correct answer: C
Rationale: The correct precaution for a nurse caring for a client with shigella-induced diarrhea is to wash hands before and after client care. Shigella is a highly contagious bacterium that spreads through contaminated food, water, or contact with infected individuals. While wearing gloves is important when directly handling bodily fluids, hand hygiene is crucial in preventing the transmission of the infection. Wearing a mask or using an N95 respirator is not necessary for preventing the spread of shigella, as it primarily spreads through the fecal-oral route rather than through respiratory droplets.
2. The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care?
- A. Limit explanation of procedures because the child is preschool-aged
- B. Ask that all family members leave the room when performing procedures
- C. Allow the child to choose the type of juice to drink with the administration of oral medications
- D. Explain that EMLA cream cannot be used for the morning lab draw because there is not time for it to be effective
Correct answer: C
Rationale: Allowing the child to make choices, such as selecting the type of juice, helps to maintain a sense of control and reduce anxiety, ensuring atraumatic care.
3. When teaching a patient about the use of finasteride (Proscar) for benign prostatic hyperplasia (BPH), what should the nurse emphasize about the expected outcomes of this therapy?
- A. Expect improvement in symptoms within a few days.
- B. Improvement in symptoms may take several weeks or months.
- C. Expect immediate improvement in urinary flow.
- D. The medication will cure BPH after treatment is complete.
Correct answer: B
Rationale: The correct answer is B. The effects of finasteride in treating BPH may take several weeks or months to become noticeable as it works by shrinking the prostate gland over time. Therefore, patients should be informed that improvement in symptoms may not be immediate. Choice A is incorrect because improvement in symptoms is not expected within a few days. Choice C is incorrect as immediate improvement in urinary flow is not typical with finasteride. Choice D is incorrect because finasteride manages BPH symptoms but does not cure the condition.
4. Before administering a live virus vaccine to a patient taking a glucocorticoid medication, what action should the nurse take?
- A. Continue screening and administer the vaccine if appropriate
- B. Note the contraindication but administer the vaccine regardless
- C. Note the contraindication and clarify the order with the healthcare provider
- D. Withhold the vaccine and inform the department of health
Correct answer: C
Rationale: The correct action for the nurse to take when a patient on glucocorticoid medication is to note the contraindication and clarify the order with the healthcare provider. Glucocorticoids can suppress the immune response, potentially reducing the effectiveness of vaccines. Therefore, it is crucial to consult with the healthcare provider to assess the risks and benefits of administering a live virus vaccine in such circumstances. Administering a live virus vaccine to a patient taking glucocorticoids can increase the risk of developing a viral infection, making it essential to seek guidance from the healthcare provider before proceeding.
5. How should a healthcare professional respond to a patient who is experiencing confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Encourage deep breathing exercises
- D. Perform a neurological exam
Correct answer: A
Rationale: Administering oxygen is the most appropriate initial response to a patient experiencing confusion after surgery. Confusion can be a sign of hypoxia, which is inadequate oxygen supply to the brain. Administering oxygen helps ensure that the patient is getting enough oxygen, addressing a potential cause of the confusion. Repositioning the patient, encouraging deep breathing exercises, or performing a neurological exam may be necessary depending on the situation, but addressing potential hypoxia should be the priority in a confused post-operative patient.
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