ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is preparing to administer a high dose of morphine to a patient with terminal cancer. What is the nurse's primary consideration before administration?
- A. Ensure the family is aware of the dosage to be administered.
- B. Monitor the patient for respiratory depression.
- C. Administer the morphine in divided doses.
- D. Delay administration until the next assessment.
Correct answer: B
Rationale: The correct answer is B: Monitor the patient for respiratory depression. When administering a high dose of morphine, the nurse's primary consideration should be to monitor the patient for respiratory depression, as morphine can slow down breathing, especially in higher doses. Option A is incorrect because the primary focus should be on the patient's well-being and safety rather than family awareness at this point. Option C is not the best approach as the immediate concern is monitoring the patient closely for any adverse effects. Option D is not advisable as delaying administration without a valid reason can compromise pain management in a terminal cancer patient.
2. A client with renal calculi is admitted. What is the priority nursing intervention?
- A. Monitor urinary output every shift.
- B. Administer pain medication as ordered.
- C. Strain all urine for stones.
- D. Increase fluid intake to flush the urinary tract.
Correct answer: C
Rationale: The correct answer is to strain all urine for stones. This is the priority nursing intervention for a client with renal calculi as it helps in identifying and preventing stones from passing unnoticed. Monitoring urinary output, administering pain medication, and increasing fluid intake are important aspects of care for this client, but the priority is to ensure that any passed stones are collected and analyzed to guide further treatment.
3. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?
- A. Wear a gown, gloves, face mask, and goggles for interactions with the patient.
- B. Transport the patient safely and quickly when going to the radiology department.
- C. Place the patient in a room with negative airflow.
- D. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.
Correct answer: D
Rationale: The correct answer is to use a dedicated blood pressure cuff that stays in the room and is used for that patient only. Patients on contact precautions require dedicated equipment to prevent the spread of disease. Using one blood pressure cuff exclusively for the patient on contact precautions helps minimize the risk of transmitting infections to other patients. Choices A, B, and C are incorrect because while wearing protective gear and isolating the patient in a room with negative airflow are important infection control measures, using dedicated equipment for the patient on contact precautions is specifically recommended to prevent the spread of disease in this scenario.
4. A community health nurse is reviewing primary prevention strategies for West Nile virus with a group of clients in a rural health clinic. Which of the following instructions should the nurse include?
- A. Avoid exposure to deer ticks.
- B. Eliminate areas of standing water.
- C. Use a respiratory mask when cleaning bird coops.
- D. Plan outdoor activities after dusk.
Correct answer: B
Rationale: The correct answer is B: 'Eliminate areas of standing water.' This is an essential primary prevention strategy for West Nile virus as it helps prevent the breeding of mosquitoes that spread the virus. Choices A, C, and D are incorrect. Avoiding exposure to deer ticks is more relevant for Lyme disease, using a respiratory mask when cleaning bird coops is not a primary prevention strategy for West Nile virus, and planning outdoor activities after dusk does not directly address the prevention of West Nile virus transmission.
5. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?
- A. Drink fluids between meals
- B. Eat three large meals each day
- C. Lie down for 30 minutes after meals
- D. Avoid drinking liquids with meals
Correct answer: D
Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.
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