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. When working with a client who does not speak the same language, which of the following actions should the nurse take?
- A. Speak directly to the interpreter
- B. Use family members to translate
- C. Speak directly to the patient
- D. Use medical jargon
Correct answer: C
Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.
3. A client has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?
- A. Lemon sherbet
- B. Milkshake
- C. Vanilla ice cream
- D. Grape juice
Correct answer: D
Rationale: Grape juice is the correct choice for a clear liquid diet because it is a liquid that is transparent and does not contain any solid particles. Lemon sherbet, milkshake, and vanilla ice cream are not appropriate for a clear liquid diet as they all contain solid particles or are not in liquid form.
4. What is the most appropriate action for handling hazardous drugs?
- A. Wear gloves and wash hands after handling.
- B. Store the drugs according to manufacturer instructions.
- C. Discard unused drugs in regular trash.
- D. Wear personal protective equipment (PPE) when handling hazardous drugs.
Correct answer: D
Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.
5. A healthcare provider is assessing a patient with chronic pain. Which finding is most concerning?
- A. The patient reports a pain level of 6 on a scale of 0 to 10.
- B. The patient is lying still and refuses to move.
- C. The patient's pain persists despite medication.
- D. The patient reports feeling anxious and restless.
Correct answer: C
Rationale: In the context of chronic pain management, the most concerning finding is when the patient's pain persists despite medication. This suggests inadequate pain control or the need for a re-evaluation of the treatment plan. Choices A, B, and D are not as concerning in this scenario. A pain level of 6 on a scale of 0 to 10 is moderate and may be manageable with appropriate interventions. Patients with chronic pain can sometimes lie still due to pain or other reasons, and anxiety and restlessness are common in individuals with pain conditions but may not necessarily indicate a critical issue like uncontrolled pain.
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