ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse is preparing a client for surgery. The client refuses to remove a religious medal. What is the nurse's best response?
- A. Ask the family to remove the medal
- B. Place the medal in a safe place for the client
- C. Allow the client to keep the medal during surgery
- D. Inform the client that the medal must be removed
Correct answer: C
Rationale: The correct answer is to allow the client to keep the medal during surgery. Clients may retain religious medals or jewelry during surgery if it does not interfere with the procedure. Asking the family to remove the medal (Choice A) may not be respecting the client's wishes. Placing the medal in a safe place for the client (Choice B) may cause distress to the client who wants to keep it. Informing the client that the medal must be removed (Choice D) disregards the client's beliefs and preferences.
2. A client has a new prescription for folic acid and believes it's only for pregnant women. What statement should the nurse make?
- A. Folic acid is important only for pregnant women.
- B. You don’t need folic acid if you eat a balanced diet.
- C. Folic acid is important for the building of blood cells for adults and children.
- D. You should take folic acid only if your blood tests show a deficiency.
Correct answer: C
Rationale: The correct answer is C because folic acid is essential for the production of red blood cells in adults and children, not just for pregnant women. Option A is incorrect as folic acid is not exclusive to pregnant women. Option B is incorrect as a balanced diet may not provide sufficient folic acid. Option D is incorrect since folic acid supplementation is also recommended for other reasons beyond deficiency.
3. Which principle is most important for maintaining medical asepsis in a healthcare setting?
- A. Sterilize instruments only when visibly contaminated.
- B. Use sterile gloves for all patient interactions.
- C. Disinfect patient areas only at the end of the day.
- D. Clean hands thoroughly before and after patient contact.
Correct answer: D
Rationale: The correct answer is D: Clean hands thoroughly before and after patient contact. Hand hygiene is crucial for maintaining medical asepsis in a healthcare setting as it helps prevent the spread of infections between patients and healthcare workers. Choice A is incorrect because instruments should be sterilized regularly, not just when visibly contaminated. Choice B is incorrect as sterile gloves are not required for all patient interactions, only for specific procedures. Choice C is incorrect because patient areas should be disinfected regularly throughout the day, not just at the end of the day.
4. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?
- A. Brachial pulse in the right arm
- B. Radial pulse in the right arm
- C. Brachial pulse in the left arm
- D. Radial pulse in the left arm
Correct answer: D
Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.
5. A nurse is teaching a patient with hypertension about the DASH diet. What is the most important instruction to include?
- A. Increase the patient's intake of fruits and vegetables.
- B. Limit the patient's intake of saturated fats.
- C. Encourage the patient to reduce sodium intake.
- D. Recommend the patient avoid caffeine.
Correct answer: C
Rationale: The correct answer is to encourage the patient to reduce sodium intake. The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes reducing sodium intake to help manage hypertension. While increasing fruits and vegetables (Choice A) is important in the DASH diet, reducing sodium intake is considered more crucial. Limiting saturated fats (Choice B) is beneficial but not as critical as reducing sodium. Avoiding caffeine (Choice D) is not a specific recommendation of the DASH diet for managing hypertension.
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