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 client with hyperthyroidism is prescribed propranolol. Which finding indicates that the propranolol is effective?
- A. The client reports an increase in weight
- B. The client has a decrease in blood pressure
- C. The client reports an increase in energy
- D. The client's respiratory rate has increased
Correct answer: B
Rationale: The correct answer is B because a decrease in blood pressure is an expected outcome when propranolol, a beta-blocker, is effectively managing hyperthyroidism. Propranolol helps control symptoms such as tachycardia and hypertension associated with hyperthyroidism. Choices A, C, and D are incorrect because weight gain, increased energy, and an increased respiratory rate are not direct indicators of propranolol's effectiveness in treating hyperthyroidism.
3. The healthcare provider is assessing an immobile patient for deep vein thrombosis (DVT). What should the healthcare provider do?
- A. Lightly rub the lower leg to check for redness and tenderness.
- B. Apply elastic stockings every 4 hours.
- C. Measure the calf circumference of both legs.
- D. Flex the foot while assessing for patient discomfort.
Correct answer: C
Rationale: Measuring the calf circumference of both legs is crucial when assessing for DVT in an immobile patient. A significant increase in the circumference of one calf compared to the other suggests the presence of a deep vein thrombosis. Option A is incorrect because rubbing the lower leg may dislodge a clot if present. Option B is incorrect as elastic stockings should not be removed frequently as this can increase the risk of clot formation. Option D is incorrect as dorsiflexing the foot can lead to pain and should not be done to assess for DVT.
4. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?
- A. Administer emergency medications without performing CPR
- B. Begin CPR
- C. Call the provider for a do-not-resuscitate (DNR) order
- D. Respect the client's wishes, and do not attempt CPR
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.
5. When teaching a patient with a new prescription for brimonidine to treat open-angle glaucoma, what indicates an understanding of the instructions?
- A. I can expect my vision to improve quickly
- B. I should use it only when my eyes are irritated
- C. I can expect to feel some irritation when I put these drops in my eyes
- D. I will need regular eye exams
Correct answer: C
Rationale: The correct answer is C. When using brimonidine to treat open-angle glaucoma, patients may experience temporary irritation in the eyes. Choice A is incorrect because vision improvement from brimonidine is not immediate. Choice B is incorrect as brimonidine should be used as prescribed, not just when eyes are irritated. Choice D is important but does not directly indicate an understanding of the medication's use.
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