ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?
- A. The nursing student wears gloves when changing bed linens.
- B. The nursing student wears gloves to remove a wound dressing.
- C. The nursing student washes hands after removing gloves.
- D. The nursing student touches the patient's skin with sterile gloves.
Correct answer: D
Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.
2. A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Abruptio placentae
- C. Post maturity
- D. Head compression
Correct answer: D
Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.
3. What is considered fast breathing in a 13-month-old child if the respiratory rate (RR) exceeds which value?
- A. 40 breaths per minute
- B. 50 breaths per minute
- C. 60 breaths per minute
- D. 30 breaths per minute
Correct answer: C
Rationale: In the context of pediatric care, a respiratory rate of more than 60 breaths per minute in a child aged 13 months is considered fast breathing, hence option 'C' is correct. Options 'A', 'B', and 'D' are incorrect as they do not meet the specified criteria for fast breathing in a 13-month-old. Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, including monitoring respiratory rates, to ensure that interventions are appropriately targeted and outcomes are optimized.
4. A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You should expect your urine to turn orange while taking this medication.
- C. This medication can cause you to gain weight.
- D. Take this medication with food to reduce gastrointestinal discomfort.
Correct answer: D
Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.
5. What should Mrs. Smith do to increase her HDL levels, as advised by the nurse?
- A. Monitor her blood glucose levels
- B. Quit smoking
- C. Control her blood pressure
- D. Take fish oil supplements
Correct answer: B: Quit smoking
Rationale: The correct answer is 'Quit smoking.' Smoking has been shown to lower HDL (High-Density Lipoprotein) levels, and quitting can help to improve these levels. HDL is often referred to as 'good cholesterol' because it helps to remove other forms of cholesterol from the bloodstream, reducing the risk of heart disease. While monitoring blood glucose levels, controlling blood pressure, and taking fish oil supplements can contribute to overall health and wellbeing, they do not directly increase HDL levels in the same way that quitting smoking does. Therefore, quitting smoking is the most effective way for Mrs. Smith to increase her HDL levels as advised by the nurse.
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