ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is preparing medications for a client via nasogastric tube. What should the nurse do before administering the medications?
- A. Flush the tube with water and administer all medications at once
- B. Administer medications one after the other without flushing
- C. Crush all medications and mix them together for administration
- D. Administer medications in liquid form only
Correct answer: B
Rationale: Before administering medications through a nasogastric tube, the nurse should administer them one after the other without flushing. Flushing the tube with water should be done before and after each medication to prevent any interactions and ensure each medication is delivered effectively. The correct answer is not to administer all medications at once (choice A) as this can lead to potential drug interactions. Crushing all medications and mixing them together (choice C) is incorrect as each medication should be given separately to maintain their individual efficacy. Administering medications in liquid form only (choice D) is limiting and may not be suitable for all types of medications that need to be administered.
2. A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?
- A. Limit the client's sodium intake to 4 grams per day.
- B. Measure the client's abdominal girth daily.
- C. Monitor the client's urine specific gravity every 12 hours.
- D. Encourage the client to drink 3 liters of fluid per day.
Correct answer: B
Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.
3. A teacher states to the school nurse, 'I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?' Which should the nurse include in the response to the teacher?
- A. The child has a crush on the teacher.
- B. The child has increased intracranial pressure.
- C. The child may have had a head injury.
- D. The child is experiencing absence seizures.
Correct answer: D
Rationale: Staring spells that end abruptly and are followed by normal activity are indicative of absence seizures. In absence seizures, a child may exhibit staring spells, brief loss of awareness, and lack of responsiveness, which can last for a few seconds. Choice A is incorrect because the behavior described is not associated with having a crush. Choice B is incorrect as increased intracranial pressure usually presents with other symptoms. Choice C is less likely as a head injury would typically manifest with additional signs beyond just staring and blinking.
4. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?
- A. Ensure that the bed linen is always dry
- B. Frequently check the bed for wetness and keep it dry
- C. Place a rubber sheet under the client's buttocks
- D. Keep the patient clean and dry
Correct answer: A
Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.
5. A patient on a low-sodium diet should avoid which of the following foods?
- A. Fresh fruits
- B. Unsalted nuts
- C. Canned soup
- D. Plain rice
Correct answer: C
Rationale: Canned soup is the correct answer. Canned soups are often high in sodium due to added salt and should be avoided on a low-sodium diet. Fresh fruits (Choice A) are typically low in sodium and a good choice for a low-sodium diet. Unsalted nuts (Choice B) are also low in sodium and can be included in a low-sodium diet. Plain rice (Choice D) is a low-sodium food and can be part of a low-sodium diet.
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