ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A healthcare provider is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the healthcare provider include in the teaching? (SATA)
- A. Vitamin B12
- B. Vitamin C
- C. Vitamin K
- D. Vitamin D
Correct answer: B
Rationale: The correct answer is Vitamin C. Vitamin C is essential for wound healing due to its role in collagen production. Collagen is crucial for wound repair and the formation of new tissue. Vitamin B12 is important for nerve function and DNA synthesis but is not directly related to wound healing. Vitamin K is essential for blood clotting and bone health but does not directly promote wound healing. Vitamin D plays a role in bone health and immune function but is not a primary vitamin involved in wound healing.
2. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?
- A. Crush all medications and administer them all at once.
- B. Flush the NG tube before and after each medication.
- C. Administer only liquid forms of medications.
- D. Skip flushing the tube entirely.
Correct answer: B
Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.
3. While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?
- A. Blood pressure
- B. Heart rate
- C. Respiratory rate
- D. Temperature
Correct answer: C
Rationale: The correct answer is monitoring the respiratory rate. Morphine can depress respiratory function, leading to respiratory depression or arrest. Therefore, closely monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress. While blood pressure, heart rate, and temperature are important assessments, in this scenario, respiratory rate takes precedence due to the potential respiratory complications associated with morphine administration.
4. What is the most important nursing intervention for a patient with diarrhea?
- A. Encourage the patient to increase fluid intake.
- B. Monitor the patient's skin integrity.
- C. Check the patient's electrolyte levels.
- D. Educate the patient about infection control measures.
Correct answer: B
Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.
5. A client with severe dyspnea is scheduled for multiple diagnostic tests. Which test should the nurse prioritize?
- A. Administer an echocardiogram first.
- B. Prioritize a chest x-ray for the client.
- C. Prepare the client for a CT scan.
- D. Order an MRI first.
Correct answer: B
Rationale: The correct answer is B: Prioritize a chest x-ray for the client. When a client presents with severe dyspnea, a chest x-ray should be prioritized as it helps in assessing the lungs and heart, which are crucial in cases of respiratory distress. Echocardiograms are more focused on assessing heart function and may not provide immediate information needed in cases of dyspnea. CT scans and MRIs are more detailed imaging studies that are not typically the first-line diagnostic tests for severe dyspnea.
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