ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?
- A. Suction the tracheostomy to maintain a patent airway.
- B. Administer pain medication as prescribed.
- C. Change the tracheostomy dressing every 4 hours.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.
2. A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to participate in developing a system of rewards.
- B. Arrange for someone to remain with the client for 30 minutes after meals.
- C. Offer the client a selection of beverages at each meal.
- D. Inform the client that a weight gain of 2.3 kg per week is expected.
Correct answer: A
Rationale: Encouraging the client to participate in developing a system of rewards is an essential part of the plan of care for a client with anorexia nervosa. This action can help motivate and engage the client in their treatment plan, promoting a sense of achievement and progress. Choice B, arranging for someone to remain with the client for 30 minutes after meals, may not address the underlying issues related to anorexia nervosa and could potentially disrupt the client's independence. Choice C, offering a selection of beverages at each meal, is not directly related to addressing the client's condition of anorexia nervosa. Choice D, informing the client about an expected weight gain, could increase anxiety and may not be appropriate without considering the client's individual progress and readiness.
3. Which enzyme is most essential for the digestion of triglycerides found in butterfat?
- A. Gastric lipase
- B. Pepsin
- C. Mucus
- D. Intrinsic factor
Correct answer: A
Rationale: The correct answer is A: Gastric lipase. Gastric lipase is crucial for the digestion of short- and medium-chain triglycerides, such as those found in butterfat. Pepsin is involved in protein digestion, not lipid digestion. Mucus acts as a protective barrier in the stomach and does not play a direct role in lipid digestion. Intrinsic factor is involved in the absorption of vitamin B12 and is not related to the digestion of triglycerides.
4. How should a healthcare professional monitor a patient receiving IV potassium?
- A. Monitor urine output
- B. Check blood pressure
- C. Monitor IV site
- D. Check respiratory rate
Correct answer: C
Rationale: When a patient is receiving IV potassium, it is crucial to monitor the IV site. Potassium can be irritating to the veins and may cause phlebitis or infiltration. Monitoring the IV site allows early detection of any potential complications. Checking urine output (Choice A) is important to assess kidney function but is not directly related to monitoring IV potassium. Blood pressure (Choice B) and respiratory rate (Choice D) are essential vital signs to monitor in general patient care but are not specific to monitoring IV potassium administration.
5. Which of the following bones is a component of the appendicular skeleton?
- A. Xiphoid process
- B. Symphysis pubis
- C. Sacrum
- D. Sternum
Correct answer: Symphysis pubis
Rationale: The correct answer is B: Symphysis pubis. The symphysis pubis is a component of the appendicular skeleton, specifically part of the pelvic girdle. The xiphoid process (Choice A) is part of the axial skeleton, located at the lower end of the sternum. The sacrum (Choice C) is also part of the axial skeleton, forming the posterior part of the pelvis. The sternum (Choice D) is part of the axial skeleton, located in the center of the chest.
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