ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a patient postoperatively after a thyroidectomy. Which of the following findings should be reported immediately?
- A. Hoarseness
- B. Difficulty swallowing
- C. Numbness in the fingers
- D. Tingling around the mouth
Correct answer: D
Rationale: Tingling around the mouth should be reported immediately as it may indicate hypocalcemia, a serious complication resulting from accidental removal or damage to the parathyroid glands during thyroidectomy. Hoarseness and difficulty swallowing are common post-thyroidectomy symptoms related to the surgery itself and the manipulation of the vocal cords and nearby structures. Numbness in the fingers is not typically associated with immediate serious complications of a thyroidectomy.
2. A nurse notices another nurse skipping hand hygiene. What is the appropriate course of action?
- A. Ignore the situation to maintain team harmony.
- B. Report the behavior to the supervisor.
- C. Discuss the issue with the nurse directly.
- D. Do nothing and continue with patient care.
Correct answer: B
Rationale: Correct hand hygiene is crucial for preventing the spread of infections and ensuring patient safety. When a nurse observes another healthcare worker skipping hand hygiene practices, it is essential to report this behavior to the supervisor. Reporting ensures that appropriate action is taken to address the issue and maintain a safe environment for patients. Ignoring the situation (Choice A) may compromise patient safety. Discussing the issue directly with the nurse (Choice C) may not always be effective in ensuring compliance. Doing nothing and continuing with patient care (Choice D) disregards the importance of infection control protocols.
3. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?
- A. Restrict the patient's fluid intake.
- B. Monitor the patient's daily weight.
- C. Administer diuretics as prescribed.
- D. Increase the patient's salt intake to promote fluid balance.
Correct answer: B
Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.
4. A healthcare provider is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The healthcare provider should recommend which of the following foods as the best source of protein to promote wound healing?
- A. One cup of brown rice
- B. One cup of pureed avocado
- C. One cup of lentils
- D. One cup of orange juice
Correct answer: C
Rationale: Lentils are an excellent source of protein, suitable for a vegan diet, and promote wound healing. Brown rice (Choice A) is a carbohydrate-rich food and lacks sufficient protein for wound healing. Pureed avocado (Choice B) is a healthy fat source but low in protein. Orange juice (Choice D) is a source of vitamin C but lacks protein needed for wound healing.
5. A patient with chronic kidney disease has been prescribed a low-protein diet. What is the nurse's priority intervention?
- A. Encourage the patient to eat small, frequent meals.
- B. Monitor the patient's intake and output.
- C. Educate the patient on the benefits of a low-protein diet.
- D. Monitor the patient's protein intake closely.
Correct answer: D
Rationale: The correct answer is to monitor the patient's protein intake closely. In patients with chronic kidney disease on a low-protein diet, monitoring protein intake is crucial to prevent complications such as malnutrition or inadequate nutrient intake. Encouraging small, frequent meals (Choice A) can be beneficial but is not the priority over monitoring protein intake. Monitoring intake and output (Choice B) is important but does not directly address the specific focus on protein intake. Educating the patient on the benefits of a low-protein diet (Choice C) is essential but not as immediate as monitoring the actual protein intake.
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