ATI RN
ATI Capstone Comprehensive Assessment B
1. A patient is at risk for impaired skin integrity. What is the priority intervention for the nurse?
- A. Turn and reposition the patient every 2 hours.
- B. Apply a moisture barrier to the patient's skin.
- C. Massage the patient's skin to promote circulation.
- D. Apply a heating pad to the patient's skin to increase blood flow.
Correct answer: A
Rationale: The correct answer is to turn and reposition the patient every 2 hours. This intervention is crucial in preventing pressure ulcers and maintaining skin integrity by relieving pressure on bony prominences. Applying a moisture barrier (Choice B) is important for moisture-associated skin damage but is not the priority in this case. Massaging the patient's skin (Choice C) can potentially cause friction and shear, increasing the risk of skin breakdown. Applying a heating pad (Choice D) can lead to burns or thermal injuries, exacerbating skin integrity issues.
2. What are the complications of diabetes mellitus that a nurse should monitor for?
- A. Peripheral neuropathy and retinopathy
- B. All of the above
- C. Diabetic ketoacidosis and hyperosmolar hyperglycemic state
- D. Nephropathy and cardiovascular disease
Correct answer: D
Rationale: The correct answer is D. Complications of diabetes mellitus that a nurse should monitor for include nephropathy and cardiovascular disease, in addition to diabetic ketoacidosis, hyperosmolar hyperglycemic state, neuropathy, and retinopathy. While choices A and C mention some complications of diabetes, they do not cover all the complications that a nurse should monitor for. Choice B is incorrect as it suggests selecting all options, which is not accurate.
3. A patient has a new prescription for allopurinol to treat gout. What should the nurse include in the teaching?
- A. Decrease protein intake
- B. Limit salt intake
- C. Increase fluid intake
- D. Limit alcohol
Correct answer: C
Rationale: Correct answer: Increasing fluid intake is essential when taking allopurinol to prevent kidney stones and aid in uric acid excretion. This helps reduce the risk of developing complications associated with gout. Decreasing protein intake (Choice A) is not directly related to allopurinol therapy. Limiting salt intake (Choice B) and alcohol consumption (Choice D) are important for overall health but are not specific recommendations when taking allopurinol for gout.
4. If a client refuses surgery, but the family insists, what should the nurse do in this situation?
- A. Respect the family's decision and proceed with the surgery.
- B. Respect the client's decision and notify the healthcare provider.
- C. Try to mediate between the family and the client.
- D. Encourage the client to follow their family's wishes.
Correct answer: B
Rationale: In this situation, the nurse should respect the client's decision and notify the healthcare provider. The client has the right to refuse treatment, and the nurse must advocate for the client's autonomy. Proceeding with the surgery against the client's wishes would violate their autonomy and ethical principles. Trying to mediate between the family and the client may be appropriate, but ultimately, the client's decision should be respected. Encouraging the client to follow their family's wishes disregards the client's autonomy and is not ethically appropriate.
5. A nurse manager notices a discrepancy in a nurse's narcotics record. What is the appropriate action?
- A. Ask the nurse for clarification about the record.
- B. Report the discrepancy to the pharmacy.
- C. Report the issue to the nurse manager immediately.
- D. Ignore the discrepancy as a clerical error.
Correct answer: B
Rationale: The appropriate action when a nurse manager notices a discrepancy in a nurse's narcotics record is to report the discrepancy to the pharmacy. Reporting such discrepancies is crucial to ensure accountability and patient safety. Choice A is incorrect because the nurse manager should not confront the nurse directly without proper investigation. Choice C is incorrect because reporting to the nurse manager may not address the issue effectively. Choice D is incorrect because ignoring the discrepancy can compromise patient safety and violates protocols.
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