ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse is caring for a patient who has just returned from surgery. What is the nurse's priority action?
- A. Monitor the patient's pain level.
- B. Assess the patient's vital signs.
- C. Assess the surgical incision site.
- D. Position the patient in a high Fowler's position.
Correct answer: B
Rationale: The correct answer is B: Assess the patient's vital signs. Assessing vital signs is crucial as it helps to detect any early signs of complications such as bleeding, shock, or changes in oxygenation. Monitoring the patient's pain level (Choice A) is important but assessing vital signs takes precedence. While assessing the surgical incision site (Choice C) is essential, ensuring the patient's physiological stability through vital sign assessment is the priority. Positioning the patient in a high Fowler's position (Choice D) may be necessary for comfort but does not address the immediate need to assess the patient's condition post-surgery.
2. A nurse is presenting educational materials for a group of middle-aged clients about menopausal hormone therapy following a total hysterectomy. Which of the following information should the nurse include?
- A. Take at different times of the day
- B. Prevents from having a cerebral hemorrhage
- C. Prevents osteoporotic fractures
- D. Take an extra dose if missed a day
Correct answer: C
Rationale: The correct information the nurse should include is that menopausal hormone therapy helps prevent osteoporotic fractures by maintaining bone density. Option A is incorrect as hormone therapy should be taken consistently at the same time each day for optimal effectiveness. Option B is incorrect as menopausal hormone therapy is not primarily aimed at preventing cerebral hemorrhage. Option D is incorrect because taking an extra dose is not recommended if a dose is missed; instead, the missed dose should be taken as soon as remembered, unless it is close to the time for the next dose.
3. A healthcare provider is providing teaching for a patient with a prescription for oral metronidazole, what is the priority teaching point?
- A. Report headaches
- B. Report a rash
- C. Avoid sunlight
- D. Take with meals
Correct answer: B
Rationale: The correct answer is to 'Report a rash.' Metronidazole can cause severe adverse reactions like Stevens-Johnson syndrome, a life-threatening rash. It is crucial to educate the patient to report any rash immediately to prevent serious complications. Choices A, C, and D are incorrect because while they may be relevant to consider during metronidazole therapy, they are not the priority teaching point. Headaches can occur but are not as serious as a rash; avoiding sunlight is more related to doxycycline, not metronidazole; and taking with meals is a general instruction for some medications but not the priority teaching point for metronidazole.
4. A patient with a history of hypertension is admitted for chest pain. What is the most appropriate action for the nurse to take first?
- A. Obtain a detailed medical history
- B. Administer nitroglycerin
- C. Conduct an ECG
- D. Administer morphine sulfate
Correct answer: B
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient presenting with chest pain as it helps dilate blood vessels, reduce chest pain, and improve oxygen supply to the heart. Obtaining a detailed medical history, conducting an ECG, or administering morphine sulfate are important steps in the assessment and treatment process but are secondary to the immediate need to address chest pain and potential cardiac ischemia.
5. A healthcare provider writes a prescription for a medication dose three times the normal range. What should the nurse do?
- A. Administer the medication as prescribed
- B. Question the prescription with the provider
- C. Consult with the pharmacist about the dosage
- D. Delay the medication until verification can be made
Correct answer: B
Rationale: The correct action for the nurse in this situation is to question the prescription with the provider. Administering a medication dose three times the normal range without clarification could pose serious risks to the client. Consulting with the pharmacist about the dosage or delaying the medication until verification can be made are not the initial steps to take; the nurse should first clarify the prescription with the healthcare provider to ensure patient safety.
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