ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A healthcare professional is caring for a client with impaired mobility. Which of the following support devices should the healthcare professional plan to use to prevent the client from developing plantar flexion contractures?
- A. Sheepskin heel pad
- B. Footboard
- C. Trochanter roll
- D. Abduction pillow
Correct answer: B
Rationale: A footboard is the correct choice to prevent plantar flexion contractures by maintaining proper alignment of the feet. Plantar flexion contractures involve the foot pointing downward, and a footboard helps keep the foot in a neutral position. Choice A, the sheepskin heel pad, is used for pressure ulcer prevention and comfort but does not specifically address plantar flexion contractures. Choice C, the trochanter roll, is used for hip positioning, not foot alignment. Choice D, the abduction pillow, is used to maintain proper positioning of the legs but does not directly address plantar flexion contractures.
2. A nurse is teaching a client who has a new prescription for amoxicillin clavulanate to treat pharyngitis. Which statement indicates understanding?
- A. I will double my dose if I miss one
- B. I should take this medication on an empty stomach between meals
- C. I will take the medication until my sore throat goes away
- D. I will stop taking this medication if I develop itching
Correct answer: C
Rationale: The client should never double the dose if a dose is missed. This can lead to an overdose, which can cause serious adverse effects. Instead, the client should take the next dose as scheduled or consult the provider for guidance.
3. 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.
4. A healthcare professional is giving a change-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is the priority for the healthcare professional to provide?
- A. Recent chest x-ray results
- B. Medication history
- C. Breath sounds
- D. Lab results
Correct answer: C
Rationale: The correct answer is C: 'Breath sounds.' When providing a change-of-shift report for a client with pneumonia, the priority information to communicate is the assessment of breath sounds. Monitoring breath sounds is crucial in assessing respiratory status and the effectiveness of treatments in pneumonia. Option A, recent chest x-ray results, may be important but does not provide real-time information on the client's current status. Option B, medication history, is relevant but not as immediate as assessing breath sounds. Option D, lab results, can provide valuable information but may not be as urgent as monitoring the client's respiratory status through breath sounds.
5. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?
- A. Lock beds and wheelchairs when not in use
- B. Administer a sedative at bedtime
- C. Provide information about home safety checks
- D. Teach balance and strengthening exercises
Correct answer: A
Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.
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