ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A nurse is preparing an in-service about family violence for a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?
- A. Perpetrators of family-directed violence do not recognize their behavior as abnormal.
- B. Female clients who experience partner violence are at greater risk for chronic diseases.
- C. The victim's risk for homicide is greatest when they decide to leave the relationship.
- D. The level of violence increases over time in abusive relationships.
Correct answer: C
Rationale: The correct answer is C because the risk of homicide increases significantly when a victim decides to leave an abusive relationship. This is a crucial point to emphasize in educating healthcare professionals about family violence. Choice A is incorrect because perpetrators often do not acknowledge their behavior as abnormal. Choice B is incorrect as victims of partner violence are at greater risk for chronic, not acute, diseases. Choice D is incorrect as the level of violence tends to escalate rather than decrease over time in abusive relationships.
2. What are the nursing interventions for a patient with pneumonia?
- A. Providing fluids and rest
- B. Monitoring lung sounds and respiratory rate
- C. Encouraging coughing and deep breathing exercises
- D. Administering antibiotics and providing oxygen therapy
Correct answer: B
Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.
3. A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
- A. Finger
- B. Earlobe
- C. Toe
- D. Skin fold
Correct answer: B
Rationale: When a client has edema of both hands and thickened toenails, these conditions can impede accurate readings from the finger and toe locations. The earlobe is the best alternative site for the pulse oximeter probe in this scenario. Placing the probe on the earlobe will help ensure a more accurate measurement of oxygen saturation despite the issues with the hands and toenails. Therefore, the correct answer is to apply the pulse oximeter probe to the earlobe. Choices A, C, and D are incorrect because of the potential limitations presented by the edema and thickened toenails.
4. The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, 'I always get a rash when I eat shellfish.' Which of the following is the priority nursing action?
- A. Attach a wristband indicating the client's allergy
- B. Ask the client if any other foods cause such a reaction
- C. Notify the dietary department of the client's allergy
- D. Notify the provider of the client's allergy
Correct answer: D
Rationale: Notifying the provider of the client's shellfish allergy is crucial to prevent a potential reaction from the contrast dye. While attaching a wristband indicating the allergy may be necessary, the priority is to inform the provider. Asking the client about other foods causing a similar reaction or notifying the dietary department, although important, are not the priority in this situation.
5. A client had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?
- A. Maintain foam wedge between legs
- B. Monitor for shortening of the affected leg
- C. Encourage use of elastic stockings
- D. Avoid flexing the hips more than 60 degrees
Correct answer: A
Rationale: The correct answer is to maintain a foam wedge between the legs. This intervention helps prevent hip dislocation by maintaining proper leg alignment after surgery. Monitoring for shortening of the affected leg (choice B) is not directly related to preventing dislocation. Encouraging the use of elastic stockings (choice C) is more related to preventing deep vein thrombosis rather than dislocation. Avoiding flexing the hips more than 60 degrees (choice D) is important post-surgery, but it is not the most direct intervention to prevent dislocation.
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