ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
- A. Finger
- B. Earlobe
- C. Toe
- D. Skin fold
Correct answer: B
Rationale: When a client has edema of both hands and thickened toenails, these conditions can impede accurate readings from the finger and toe locations. The earlobe is the best alternative site for the pulse oximeter probe in this scenario. Placing the probe on the earlobe will help ensure a more accurate measurement of oxygen saturation despite the issues with the hands and toenails. Therefore, the correct answer is to apply the pulse oximeter probe to the earlobe. Choices A, C, and D are incorrect because of the potential limitations presented by the edema and thickened toenails.
2. A healthcare professional is reviewing the notes written by a previous shift. Which documentation reflects proper guidelines?
- A. Incomplete entries are acceptable as long as they are justified
- B. Documentation should include objective observations only
- C. Corrections in documentation should be signed and dated
- D. Entries should be modified by another healthcare professional if necessary
Correct answer: B
Rationale: The correct answer is B. Proper documentation should include objective observations and detailed notes to ensure continuity of care. Choice A is incorrect because incomplete entries can lead to gaps in information and compromise patient care. Choice C is not completely accurate as corrections should be made in a manner that does not obscure the original entry but does not necessarily require a signature. Choice D is incorrect as entries should ideally be corrected by the original author to maintain accountability and accuracy.
3. A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?
- A. Notify the provider
- B. Check the condition of the client
- C. Document the occurrence in the electronic medical record
- D. Complete an incident report
Correct answer: B
Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.
4. A healthcare professional is planning care for a client who is scheduled for a lumbar puncture. Which of the following actions should the healthcare professional include?
- A. Restrict the client's fluid intake for 4 hours following the procedure
- B. Apply cold compresses to the puncture site after the procedure
- C. Instruct the client to increase oral fluid intake after the procedure
- D. Keep the client in a prone position for 12 hours after the procedure
Correct answer: C
Rationale: The correct action to include in caring for a client scheduled for a lumbar puncture is to instruct the client to increase oral fluid intake after the procedure. Increasing oral fluid intake helps replace cerebrospinal fluid lost during the lumbar puncture and reduces the risk of headaches. Restricting fluid intake (Choice A) is not recommended as it can lead to dehydration. Applying cold compresses (Choice B) is not necessary after a lumbar puncture. Keeping the client in a prone position for 12 hours (Choice D) is not required after a lumbar puncture and can cause discomfort and complications.
5. A nurse in a clinic is caring for a client who has a urinary tract infection (UTI). Which of the following prescriptions should the nurse verify with a provider?
- A. Trimethoprim-sulfamethoxazole
- B. Hyoscyamine
- C. Oxybutynin
- D. Phenazopyridine
Correct answer: C
Rationale: The correct answer is C, Oxybutynin. Oxybutynin can worsen urinary retention, so the nurse should verify this prescription with the provider. Trimethoprim-sulfamethoxazole (Choice A) is a common antibiotic used to treat UTIs and does not require verification. Hyoscyamine (Choice B) is an anticholinergic medication used for bladder spasms and does not typically worsen UTI symptoms. Phenazopyridine (Choice D) is a urinary analgesic that helps relieve pain, burning, and discomfort caused by a UTI, which may not necessarily require verification in this scenario.
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