ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is preparing to administer medication to a client by nasogastric tube. What should the nurse do first?
- A. Administer the medication without further assessment.
- B. Check the tube placement before administering any medication.
- C. Administer the medication in liquid form only.
- D. Administer half the dosage as a precaution.
Correct answer: B
Rationale: The correct answer is B: Check the tube placement before administering any medication. Before administering medication through a nasogastric tube, the nurse must first verify the tube's correct placement to ensure the medication reaches the stomach and to prevent complications such as aspiration. Options A, C, and D are incorrect because administering medication without confirming proper tube placement can lead to serious consequences for the client.
2. A healthcare provider is reviewing the medical record of a client who has a new prescription for clozapine. Which of the following findings indicates a contraindication to clozapine?
- A. Fasting blood glucose of 120 mg/dL
- B. Asthma
- C. Hypertension
- D. WBC count of 3,300/mm3
Correct answer: D
Rationale: A low WBC count (3,300/mm3) is a contraindication to clozapine because this medication can cause severe neutropenia. Neutropenia is a significant reduction in white blood cell count, increasing the risk of infections. Elevated fasting blood glucose, asthma, and hypertension are not direct contraindications to clozapine.
3. 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.
4. Which intervention is most effective in preventing deep vein thrombosis (DVT) in a postoperative patient?
- A. Encourage the patient to drink plenty of fluids.
- B. Encourage early ambulation and leg exercises.
- C. Administer anticoagulants as prescribed.
- D. Apply compression stockings to the patient's legs.
Correct answer: B
Rationale: The most effective intervention in preventing deep vein thrombosis (DVT) in a postoperative patient is to encourage early ambulation and leg exercises. Early ambulation helps promote circulation, preventing stasis and reducing the risk of blood clot formation. Encouraging the patient to drink plenty of fluids (choice A) is important for overall health but is not the most effective intervention for preventing DVT. Administering anticoagulants (choice C) is a valuable intervention in some cases, but it may not be suitable for all postoperative patients. Applying compression stockings (choice D) can help prevent DVT but is generally not as effective as early ambulation and leg exercises in postoperative patients.
5. Which of the following is a recommended approach for handling aggressive behavior in a mental health setting?
- A. Encourage the client to express their feelings through physical activity
- B. Avoid making eye contact to prevent escalation
- C. Use pharmacological interventions immediately
- D. Maintain eye contact, offer clear choices, and set boundaries
Correct answer: D
Rationale: The recommended approach for handling aggressive behavior in a mental health setting is to maintain eye contact, offer clear choices, and set boundaries. This approach can help de-escalate the situation by establishing communication and structure. Choice A is incorrect as encouraging physical activity may not be suitable during an aggressive episode. Choice B is incorrect because avoiding eye contact can hinder communication and resolution. Choice C is also incorrect as pharmacological interventions should not be the immediate go-to method for managing aggression unless absolutely necessary.
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