ATI RN
ATI Capstone Comprehensive Assessment B
1. When caring for a patient with a nasogastric (NG) tube, what is the most appropriate intervention to prevent aspiration?
- A. Flush the NG tube with water before each feeding.
- B. Check the placement of the NG tube before each feeding.
- C. Elevate the head of the bed to 30-45 degrees.
- D. Provide the patient with oral care every 4 hours.
Correct answer: C
Rationale: Elevating the head of the bed to 30-45 degrees is the most appropriate intervention to prevent aspiration in a patient with an NG tube. This position helps reduce the risk of regurgitation and aspiration by promoting the proper flow of contents through the gastrointestinal tract and minimizing the chances of stomach contents entering the airway. Flushing the NG tube with water before each feeding may not directly prevent aspiration. Checking the placement of the NG tube is important but does not specifically address the prevention of aspiration. Providing oral care every 4 hours is essential for maintaining oral hygiene but is not directly related to preventing aspiration in a patient with an NG tube.
2. A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
- A. Hypotension
- B. Distended neck veins
- C. Slow capillary refill
- D. Weak, thready pulse
Correct answer: B
Rationale: The correct answer is B: 'Distended neck veins.' Distended neck veins are a sign of fluid volume excess, indicating an overload of fluids in the body. This can be caused by excessive fluid administration. Hypotension (choice A) is more commonly associated with fluid volume deficit. Slow capillary refill (choice C) and a weak, thready pulse (choice D) are also signs of decreased fluid volume, not fluid volume excess.
3. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?
- A. Leave one hand ungloved to assess the site.
- B. Cleanse the skin with normal saline.
- C. Ask the patient about allergies to latex or iodine.
- D. Remove excessive hair from the selected site.
Correct answer: Ask the patient about allergies to latex or iodine.
Rationale:
4. Which best describes the concept of risk?
- A. The probability that an individual will develop a specific condition
- B. The impact of a health condition on an individual's life
- C. The potential for harm from a specific condition
- D. The likelihood of being exposed to a health hazard
Correct answer: A
Rationale: The concept of risk is best described as the probability that an individual will develop a specific condition due to exposure to certain factors. It is not about the impact of a health condition on one's life (choice B), the potential harm from a specific condition (choice C), or the likelihood of being exposed to a health hazard (choice D). Understanding risk helps in assessing the chances of developing a particular health issue.
5. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?
- A. It is best to wait until the child asks about it.
- B. The best time to tell the child is between the ages of 7 and 10 years.
- C. It is not necessary to tell a child who was adopted so young.
- D. Telling the child is an important aspect of their parental responsibilities.
Correct answer: D
Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.
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