ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?
- A. 2
- B. 3
- C. 4
- D. 5
Correct answer: C
Rationale: To calculate the mL needed, divide the total dose by the dose per mL. In this case, 40 mg divided by 10 mg/mL equals 4 mL. Therefore, the nurse should administer 4 mL per dose. Choice A, 2 mL, is incorrect because it would only deliver 20 mg of furosemide, which is half the required dose. Choices B and D are also incorrect as they do not provide the accurate amount needed to achieve the 40 mg dosage.
2. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?
- A. Crush all medications and administer them all at once.
- B. Flush the NG tube before and after each medication.
- C. Administer only liquid forms of medications.
- D. Skip flushing the tube entirely.
Correct answer: B
Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.
3. A client has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent infection?
- A. Change the catheter every 72 hours.
- B. Ensure the tubing is unkinked.
- C. Empty the drainage bag every 4 hours.
- D. Hang the drainage bag below the bladder.
Correct answer: D
Rationale: The correct answer is to hang the drainage bag below the bladder. This positioning helps prevent backflow of urine, reducing the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may increase infection risk by introducing pathogens. Ensuring the tubing is unkinked promotes proper urine flow but does not directly prevent infection. Emptying the drainage bag regularly is important to prevent urinary stasis but does not directly address infection prevention.
4. A client complains of pain in the leg while in skeletal traction. What is the nurse's priority action?
- A. Increase the pain medication immediately
- B. Check for signs of infection
- C. Reposition the client's leg for comfort
- D. Notify the physician of the client's complaints
Correct answer: B
Rationale: The correct answer is B: Check for signs of infection. In skeletal traction, the priority action for the nurse when a client complains of pain in the leg is to first assess for signs of infection. Pain in skeletal traction can be a symptom of infection or other complications, so checking for signs of infection is crucial before considering other interventions. Increasing pain medication immediately (Choice A) may mask the symptoms of an underlying infection. Repositioning the client's leg for comfort (Choice C) may provide temporary relief but does not address the potential underlying issue. Notifying the physician of the client's complaints (Choice D) is important but assessing for infection should come first to ensure timely and appropriate intervention.
5. A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?
- A. Notify the family and await further instructions.
- B. Initiate CPR and call for emergency assistance.
- C. Allow the family to make decisions about care.
- D. Follow the family's wishes and perform no interventions.
Correct answer: B
Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.
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