ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client has urinary incontinence, and the nurse is caring for them. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
- A. Request a prescription for the insertion of an indwelling urinary catheter
- B. Check the client's skin every 8 hours for signs of breakdown
- C. Apply a moisture barrier ointment to the client's skin
- D. Clean the client's skin and perineum with hot water after each episode of incontinence
Correct answer: C
Rationale: The correct action to prevent skin breakdown in a client with urinary incontinence is to apply a moisture barrier ointment to the skin. This ointment helps protect the skin from the harmful effects of moisture exposure, reducing the risk of breakdown. Requesting an indwelling urinary catheter (Choice A) should not be the first-line intervention for skin breakdown prevention. Checking the client's skin for signs of breakdown (Choice B) is important but not as effective as applying a moisture barrier. Cleaning the skin with hot water (Choice D) can actually be detrimental as hot water can strip the skin of its natural oils and worsen skin integrity.
2. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?
- A. Apply liberal amount of mineral oil to the area
- B. Use karaya paste and rings around the stoma
- C. Clean the area daily with soap and water before applying bag
- D. Apply talcum powder twice a day
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. When addressing a policy violation, what is one of the initial steps to take?
- A. Terminate the employee.
- B. Confront the employee.
- C. Discipline the employee immediately.
- D. Determine whether the employee is aware of the policy.
Correct answer: D
Rationale: When addressing a policy violation, one of the initial steps should be to determine whether the employee is aware of the policy. This step allows for clarification, feedback, and potential training if needed. Terminating the employee (Choice A) or disciplining immediately (Choice C) without assessing awareness can lead to unfair treatment and legal issues. Confronting the employee (Choice B) may be necessary but should come after establishing awareness and providing necessary support or education.
4. What finding should a nurse monitor for as an adverse effect when a client has a new prescription for Spironolactone?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Hypocalcemia
- D. Hyponatremia
Correct answer: A
Rationale: The correct answer is hyperkalemia. Spironolactone is a potassium-sparing diuretic that can lead to an increase in potassium levels. Hyperkalemia can be dangerous, causing muscle weakness and cardiac dysrhythmias. Monitoring potassium levels closely is crucial when a client is on Spironolactone. Hypoglycemia (choice B) is incorrect because Spironolactone does not typically affect blood glucose levels. Hypocalcemia (choice C) and hyponatremia (choice D) are also incorrect as Spironolactone's primary impact is on potassium levels.
5. Which assessment finding is most concerning in a patient receiving morphine?
- A. Hypotension
- B. Bradycardia
- C. Respiratory depression
- D. Hypertension
Correct answer: C
Rationale: The correct answer is C, respiratory depression. When a patient is receiving morphine, respiratory depression is the most concerning side effect because it can lead to serious complications, including respiratory arrest and even death. Monitoring the patient's respiratory status is crucial to ensure early detection of any signs of respiratory depression. Choices A, B, and D are incorrect because although hypotension, bradycardia, and hypertension can occur as side effects of morphine, they are not as immediately life-threatening as respiratory depression in this context.
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