ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?
- A. Measure and document the urine in the drainage bag
- B. Remove the tape or device securing the catheter to the client's thigh
- C. Position the client supine
- D. Deflate the catheter balloon using a sterile syringe
Correct answer: A
Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.
2. Which type of bath would you recommend for a patient experiencing pruritus?
- A. Saline
- B. Colloidal (oatmeal)
- C. Water
- D. Sodium bicarbonate
Correct answer: B: Colloidal (oatmeal)
Rationale: The best choice for a pruritus (itching) patient is a colloidal (oatmeal) bath, as it is known for its soothing effect on itchy, irritated skin. Saline, water, and sodium bicarbonate baths may not provide the same level of relief for pruritus. The nursing care should involve comprehensive assessments and appropriate interventions to optimize patient outcomes. In this case, a colloidal bath is the most suitable intervention for a patient experiencing pruritus.
3. The nurse is caring postoperatively for an 8-year-old child with multiple fractures and other traumatic injuries from a motor vehicle crash. The child is experiencing severe pain. What is an important consideration in managing the child’s pain?
- A. Give only an opioid analgesic at this time.
- B. Increase the dosage of analgesic until the child is adequately sedated.
- C. Plan a preventive schedule of pain medication around the clock.
- D. Give the child a clock and explain when they can have pain medications.
Correct answer: C
Rationale: For severe postoperative pain, a preventive around-the-clock schedule is necessary to prevent decreased plasma levels of medications. Providing only an opioid analgesic at this time may not be sufficient for effective pain management. Increasing the dosage without an order is unsafe and may lead to oversedation. Planning a preventive schedule of pain medication around the clock ensures consistent pain relief and better management. Giving the child a clock and explaining when they can have pain medications may increase the child's focus on waiting for relief rather than addressing the pain promptly, making it a less effective strategy.
4. In which of the following cases is Lansoprazole not used?
- A. Gastritis
- B. Peptic Ulcers
- C. Zollinger-Ellison syndrome
- D. Thalamus hypertrophy
Correct answer: D
Rationale: Lansoprazole is a proton pump inhibitor mainly used to treat conditions related to the stomach, such as gastritis, peptic ulcers, and Zollinger-Ellison syndrome. Thalamus hypertrophy is not a condition that Lansoprazole is indicated for; it is used for gastrointestinal issues and not neurological conditions.
5. A client with asthma is being taught about peak flow meter use. Which statement by the client indicates understanding of the teaching?
- A. I will use my peak flow meter every morning.
- B. I will use my peak flow meter when I feel short of breath.
- C. I will use my peak flow meter before using my inhaler.
- D. I will use my peak flow meter after using my inhaler.
Correct answer: A
Rationale: The correct answer is A. Using the peak flow meter every morning is crucial for monitoring asthma control and making timely treatment adjustments. While using the meter when feeling short of breath or before using an inhaler can also be beneficial, the daily morning routine helps in consistent management of asthma symptoms.
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