ATI RN
ATI Capstone Comprehensive Assessment B
1. When providing discharge instructions for a patient with diabetes, what is the most important information to include?
- A. Encourage the patient to maintain a high-carbohydrate diet.
- B. Teach the patient how to monitor their blood sugar levels.
- C. Recommend the patient engage in regular exercise.
- D. Provide the patient with a list of restricted foods.
Correct answer: B
Rationale: The most critical information to include when providing discharge instructions for a patient with diabetes is teaching them how to monitor their blood sugar levels. This empowers the patient to actively manage their condition, make informed decisions about their diet and medication, and prevent complications. Encouraging a high-carbohydrate diet (Choice A) can be detrimental for diabetic patients as it may lead to unstable blood sugar levels. While regular exercise (Choice C) is important in diabetes management, monitoring blood sugar levels takes precedence. Providing a list of restricted foods (Choice D) is relevant but not as crucial as teaching the patient how to monitor their blood sugar levels.
2. What intervention should the nurse implement for a patient receiving a blood transfusion?
- A. Administer antihistamines to prevent allergic reactions.
- B. Monitor the patient for signs of circulatory overload.
- C. Ensure the blood transfusion is completed within 4 hours.
- D. Check the patient's vital signs every 30 minutes during the transfusion.
Correct answer: B
Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.
3. A nurse is caring for a female client who has osteoporosis and a new prescription for raloxifene. What should the nurse assess prior to initiating therapy?
- A. Pregnancy status
- B. Bone density
- C. Calcium levels
- D. Blood pressure
Correct answer: A
Rationale: The correct answer is A: Pregnancy status. Raloxifene is a pregnancy category X drug, which means it can cause serious birth defects. Therefore, it is crucial for the nurse to assess the client's pregnancy status before initiating therapy. Choice B, bone density, while important in osteoporosis management, is not a specific concern related to initiating raloxifene therapy. Choice C, calcium levels, and choice D, blood pressure, are not directly related to the initiation of raloxifene therapy in a female client with osteoporosis.
4. How can a healthcare professional help prevent pressure ulcers in an immobile patient?
- A. Ensuring proper nutrition and hydration
- B. Using moisture barriers to protect the skin
- C. Turning the patient every 2 hours to prevent pressure
- D. Providing special mattresses or padding
Correct answer: A
Rationale: Ensuring proper nutrition and hydration is crucial in preventing pressure ulcers in immobile patients. Adequate nutrition supports tissue health and repair, while hydration helps maintain skin elasticity. While turning the patient every 2 hours is important to prevent pressure injuries, it is not the primary way to address prevention. Using moisture barriers and providing special mattresses or padding are essential components of pressure ulcer prevention, but they are not as fundamental as ensuring proper nutrition and hydration.
5. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?
- A. Administer a diuretic as prescribed.
- B. Place the patient in a high Fowler's position.
- C. Administer oxygen via nasal cannula.
- D. Monitor the patient's lung sounds every 2 hours.
Correct answer: B
Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.
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