ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?
- A. Assess for pain relief.
- B. Monitor for respiratory depression.
- C. Assess the infusion site for complications.
- D. Increase the dosage if the client reports more pain.
Correct answer: B
Rationale: Correct answer: Before administering morphine sulfate, the nurse should monitor for respiratory depression as it is a significant side effect of this medication. Assessing for pain relief (Choice A) is important but not a pre-administration assessment. Checking the infusion site for complications (Choice C) is relevant for IV medications, not specifically for morphine sulfate. Increasing the dosage if the client reports more pain (Choice D) is not appropriate without further assessment and medical orders.
2. A healthcare provider prescribes a higher-than-usual dose of medication. What is the nurse's first action?
- A. Administer the medication and monitor closely.
- B. Hold the medication and consult the pharmacist.
- C. Ask another nurse to verify the dose.
- D. Call the provider for clarification.
Correct answer: D
Rationale: The correct answer is to call the provider for clarification. When faced with a higher-than-usual dose of medication, the nurse's first action should be to contact the prescribing healthcare provider to confirm the dosage. Administering the medication without clarifying the dose with the provider can pose serious risks to the patient's safety. Holding the medication and consulting the pharmacist may be appropriate after contacting the provider for clarification. Asking another nurse to verify the dose is not the most appropriate action when dealing with an unusual prescription; direct communication with the provider is essential in such situations.
3. A nurse is preparing to administer medications to four clients. The nurse should administer medications to which client first?
- A. A client who has pneumonia and a WBC count of 11,500/mm3 prescribed piperacillin
- B. A client who has renal failure and a serum potassium of 5.8 mEq/L prescribed sodium polystyrene sulfonate
- C. A client who is post-coronary artery bypass graft (CABG) prescribed atorvastatin
- D. A client who has anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa
Correct answer: B
Rationale: The correct answer is B. The client with renal failure and high potassium levels requires immediate attention because hyperkalemia can lead to life-threatening cardiac complications. Administering sodium polystyrene sulfonate helps lower the potassium levels. Choice A, the client with pneumonia and a high WBC count, although important, does not present an immediate life-threatening condition. Choice C, the post-CABG client prescribed atorvastatin, and Choice D, the client with anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa, do not require immediate intervention compared to managing hyperkalemia in a client with renal failure.
4. While obtaining the health and medication history of a client with a respiratory infection, the nurse learns that the client developed a rash the last time she took an antibiotic despite not being aware of any allergies. What information should the nurse provide to the client?
- A. Document the exact medication taken
- B. Ignore the symptom
- C. Stop taking antibiotics
- D. Continue with the current medication
Correct answer: A
Rationale: The correct answer is to instruct the client to document the exact medication taken. This is crucial for preventing future allergic reactions. By knowing the specific antibiotic that caused the rash, healthcare providers can avoid prescribing it again, reducing the risk of an allergic response. Choice B, 'Ignore the symptom,' is incorrect as ignoring a potential allergic reaction can lead to more severe complications. Choice C, 'Stop taking antibiotics,' is not advisable without proper guidance from a healthcare provider. Choice D, 'Continue with the current medication,' is also not recommended when there is a history of a rash related to antibiotic use.
5. Which of the following is the correct method to reduce the risk of infection when handling a urinary catheter?
- A. Clean the catheter tubing with soap and water.
- B. Maintain sterile technique when inserting the catheter.
- C. Insert the catheter using clean gloves and a clean technique.
- D. Flush the catheter tubing regularly with sterile water.
Correct answer: B
Rationale: The correct method to reduce the risk of infection when handling a urinary catheter is to maintain sterile technique when inserting the catheter. Sterile technique helps prevent introducing pathogens into the urinary system, reducing the risk of infection. Choice A is incorrect because cleaning the catheter tubing with soap and water is not sufficient for preventing infection. Choice C is incorrect as clean gloves and technique are not enough; sterile technique is necessary. Choice D is incorrect as flushing the catheter tubing with sterile water, though important for maintaining catheter patency, does not address the need for sterile technique during insertion to prevent infection.
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