ATI RN
ATI Capstone Comprehensive Assessment B
1. A healthcare professional is preparing to administer an intravenous (IV) medication. What action should the healthcare professional take to ensure patient safety?
- A. Ensure the medication is administered at the correct time.
- B. Verify the patient's identification using two identifiers.
- C. Prepare the medication at the healthcare professional's station.
- D. Ensure the medication is administered within 30 minutes of the scheduled time.
Correct answer: B
Rationale: Verifying the patient's identity using two identifiers is crucial to ensure the right patient receives the right medication. This process helps prevent medication errors by confirming the patient's identity through at least two unique identifiers, such as name, date of birth, or medical record number. Choice A is not directly related to ensuring patient safety during medication administration. Choice C is incorrect as medications should be prepared in a sterile environment, not just at the healthcare professional's station. Choice D is not a safe practice as medications should be administered at the scheduled time to maintain therapeutic effectiveness.
2. A healthcare professional is caring for a client with impaired mobility. Which of the following support devices should the healthcare professional plan to use to prevent the client from developing plantar flexion contractures?
- A. Sheepskin heel pad
- B. Footboard
- C. Trochanter roll
- D. Abduction pillow
Correct answer: B
Rationale: A footboard is the correct choice to prevent plantar flexion contractures by maintaining proper alignment of the feet. Plantar flexion contractures involve the foot pointing downward, and a footboard helps keep the foot in a neutral position. Choice A, the sheepskin heel pad, is used for pressure ulcer prevention and comfort but does not specifically address plantar flexion contractures. Choice C, the trochanter roll, is used for hip positioning, not foot alignment. Choice D, the abduction pillow, is used to maintain proper positioning of the legs but does not directly address plantar flexion contractures.
3. A client with a DNR order has requested resuscitation during a visit from the family. What is the nurse's best course of action?
- A. Follow the family's request and perform CPR.
- B. Explain to the family that the DNR must be honored.
- C. Call the healthcare provider to cancel the DNR order.
- D. Delay resuscitation until further clarification can be made.
Correct answer: B
Rationale: The correct course of action for the nurse is to explain to the family that the DNR (Do Not Resuscitate) order must be honored. It is essential for the nurse to uphold the client's wishes as documented in the DNR order. Performing CPR against the client's expressed wishes in the DNR order would violate ethical and legal standards. Calling the healthcare provider to cancel the DNR order without the client's consent is inappropriate and goes against the client's autonomy. Delaying resuscitation can be detrimental in an emergency situation and may not align with the client's wishes as outlined in the DNR order.
4. What is the primary goal when caring for a patient with chronic obstructive pulmonary disease (COPD)?
- A. Maintain the patient's oxygen saturation above 90%.
- B. Administer bronchodilators as prescribed.
- C. Improve the patient's nutritional intake.
- D. Encourage the patient to limit physical activity.
Correct answer: A
Rationale: The correct answer is to maintain the patient's oxygen saturation above 90% when caring for a patient with COPD. In COPD, impaired gas exchange leads to decreased oxygen levels in the blood. By ensuring oxygen saturation remains above 90%, healthcare providers can prevent hypoxia and its complications. Administering bronchodilators as prescribed (Choice B) is an important intervention in managing COPD symptoms, but it is not the primary goal. Improving the patient's nutritional intake (Choice C) and encouraging the patient to limit physical activity (Choice D) are also essential aspects of COPD management, but they are not the primary goal when caring for a patient with this condition.
5. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?
- A. Aspirate for a blood return before depressing the plunger
- B. Insert the needle at a 45-degree angle
- C. Administer the medication 2.54 cm (1 in) from the umbilicus
- D. The nurse should not expel the air bubble in the prefilled syringe
Correct answer: D
Rationale: The correct action when administering enoxaparin is not to expel the air bubble in the prefilled syringe. Expelling the air bubble may lead to the loss of medication and result in an incomplete dose. Aspirating for a blood return (Choice A) is not necessary for subcutaneous injections like enoxaparin. Inserting the needle at a 45-degree angle (Choice B) is not specific to administering enoxaparin. Administering the medication 2.54 cm (1 in) from the umbilicus (Choice C) is not a standard guideline for enoxaparin administration.
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