ATI RN
ATI Capstone Comprehensive Assessment B
1. A client is preparing for surgery wearing a necklace. What is the appropriate action?
- A. Remove the necklace and place it in a drawer
- B. Tape the necklace to the patient's skin
- C. Ask the patient for permission to lock it in a safe
- D. Ask the family to hold onto the necklace
Correct answer: C
Rationale: The appropriate action when a client is wearing a necklace before surgery is to ask the patient for permission to lock it in a safe. This is in line with hospital policy to secure valuables before entering surgery. Choice A is incorrect because simply placing the necklace in a drawer may not be secure. Choice B is incorrect as taping the necklace to the patient's skin can cause skin irritation and is not a standard practice. Choice D is incorrect because the responsibility for securing valuables typically lies with the healthcare team, not the patient's family.
2. When educating a client starting a new prescription for metoprolol, which instruction should the nurse include?
- A. Check your pulse before taking the medication.
- B. Take the medication with food to increase absorption.
- C. Avoid sudden changes in position.
- D. Monitor your blood pressure regularly.
Correct answer: C
Rationale: The correct instruction for a client starting metoprolol is to avoid sudden changes in position. Metoprolol can cause dizziness due to its blood pressure-lowering effects, increasing the risk of falls and injury. Instructing the client to change positions slowly helps prevent orthostatic hypotension and related adverse events. Checking the pulse before taking the medication (Choice A) is not typically necessary for metoprolol. Taking the medication with food (Choice B) is not required for absorption and can be taken with or without food. Monitoring blood pressure regularly (Choice D) is essential for clients taking metoprolol, but avoiding sudden changes in position is more critical to prevent dizziness and falls.
3. Adults often provide indirect feedback about grammar by using __________, which restructures inaccurate speech into correct form.
- A. fast-mapping
- B. an expansion
- C. overregularization
- D. a recast
Correct answer: D
Rationale: The correct answer is 'a recast.' A recast occurs when an adult rephrases a child's incorrect speech into the accurate form, aiding in the learning of proper grammar. Choice A, 'fast-mapping,' refers to the ability to learn new words quickly; choice B, 'an expansion,' typically involves adding more information to a child's speech; choice C, 'overregularization,' is an error children make when they apply grammatical rules too broadly.
4. Your patient has alcoholism, and you may suspect during your assessment that his serum magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?
- A. Tremor
- B. Pruritus
- C. Edema
- D. Decreased blood pressure
Correct answer: A
Rationale: The correct answer is A: Tremor. Signs and symptoms of hypomagnesemia primarily affect the neuromuscular system and can include tremors, confusion, tetany, laryngeal stridor, and ataxia. Pruritus (choice B) refers to itching and is not typically associated with hypomagnesemia. Edema (choice C) is swelling caused by fluid retention and is not a common manifestation of hypomagnesemia. Decreased blood pressure (choice D) is not a typical sign of hypomagnesemia; instead, low magnesium levels are more likely to cause hypertension.
5. A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined to bed. What is the most appropriate nursing intervention for this child?
- A. Providing activities for the child on restricted activity
- B. Feeding the child a protein-restricted diet
- C. Carefully handling edematous extremities
- D. Observing the child for evidence of hypotension
Correct answer: A
Rationale: The most appropriate nursing intervention for a 7-year-old child with acute glomerulonephritis experiencing gross hematuria and bed rest is to provide activities for the child on restricted activity. It is important to keep the child engaged in light activities to prevent boredom and maintain some level of physical and mental well-being. Feeding a protein-restricted diet (Choice B) is not typically indicated in this scenario unless ordered by a healthcare provider to manage kidney function. Carefully handling edematous extremities (Choice C) is important in conditions like nephrotic syndrome but is not directly related to providing appropriate care for a child with acute glomerulonephritis. Observing the child for evidence of hypotension (Choice D) is important in general nursing care but is not the most immediate or specific intervention needed for a child with acute glomerulonephritis experiencing gross hematuria and bed rest.
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