ATI RN
ATI Capstone Comprehensive Assessment B
1. A client with a history of falls is under the care of a nurse. Which intervention is most important to implement?
- A. Increase the frequency of bed checks.
- B. Use bed alarms to prevent falls.
- C. Keep the room well lit during the day.
- D. Encourage the client to use a walker for mobility.
Correct answer: B
Rationale: Using bed alarms to prevent falls is the most important intervention to implement for a client with a history of falls. Bed alarms can provide timely alerts to the healthcare team, allowing for quick assistance to prevent falls. Increasing the frequency of bed checks may not necessarily prevent falls as effectively as direct intervention with bed alarms. Keeping the room well lit is important for general safety but may not address the immediate risk of falls. Encouraging the client to use a walker for mobility is beneficial but may not be as crucial as implementing bed alarms to prevent falls in this scenario.
2. A healthcare provider is assessing a client who has been using beclomethasone for 2 weeks to manage her asthma. What is the priority to report to the provider?
- A. Sore throat
- B. Cough
- C. Chest tightness
- D. Bronchospasms
Correct answer: D
Rationale: The correct answer is D: Bronchospasms. Bronchospasms can indicate worsening asthma and are considered a severe side effect that requires immediate attention. While sore throat, cough, and chest tightness are also possible side effects of beclomethasone, bronchospasms are of higher concern due to their association with significant respiratory distress and potential exacerbation of asthma symptoms.
3. A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?
- A. Increase protein intake
- B. Monitor blood glucose levels frequently
- C. Increase the dose of insulin
- D. Reduce carbohydrate intake
Correct answer: B
Rationale: The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.
4. A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medications should the nurse include under Schedule II?
- A. Buprenorphine hydrochloride
- B. Hydrocodone bitartrate
- C. Diazepam
- D. Morphine
Correct answer: B
Rationale: The correct answer is B: Hydrocodone bitartrate. According to the Controlled Substances Act, hydrocodone bitartrate is classified as a Schedule II controlled substance due to its high potential for abuse and addiction. Diazepam (Choice C) and morphine (Choice D) are classified as Schedule IV and Schedule II controlled substances, respectively. Buprenorphine hydrochloride (Choice A) is classified as a Schedule III controlled substance. Therefore, hydrocodone bitartrate should be included under Schedule II medications when discussing the categories regulated under the Controlled Substances Act.
5. A client with HIV-1 starting therapy with ritonavir and zidovudine asks why both medications are necessary. What explanation should the nurse provide?
- A. Taking two medications ensures a faster recovery.
- B. The medications work best together to improve your immune system.
- C. Taking the 2 medications together keeps you from becoming resistant to either of them.
- D. These medications target different parts of the virus.
Correct answer: C
Rationale: The correct answer is C because taking two medications together helps prevent the development of drug resistance in HIV treatment. Choice A is incorrect because the primary goal of combination therapy is not necessarily a faster recovery. Choice B is incorrect as the main purpose of combining medications in HIV treatment is to prevent resistance rather than improving the immune system. Choice D is incorrect because while it is true that the medications may target different parts of the virus, the main reason for using both together is to prevent resistance.
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