ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A healthcare provider is providing teaching for a patient with a prescription for oral metronidazole, what is the priority teaching point?
- A. Report headaches
- B. Report a rash
- C. Avoid sunlight
- D. Take with meals
Correct answer: B
Rationale: The correct answer is to 'Report a rash.' Metronidazole can cause severe adverse reactions like Stevens-Johnson syndrome, a life-threatening rash. It is crucial to educate the patient to report any rash immediately to prevent serious complications. Choices A, C, and D are incorrect because while they may be relevant to consider during metronidazole therapy, they are not the priority teaching point. Headaches can occur but are not as serious as a rash; avoiding sunlight is more related to doxycycline, not metronidazole; and taking with meals is a general instruction for some medications but not the priority teaching point for metronidazole.
2. What is the priority when assessing a patient for possible deep vein thrombosis (DVT)?
- A. Dorsiflex the foot and check for pain.
- B. Measure the calf circumference of both legs.
- C. Check the skin for signs of redness.
- D. Perform a Doppler ultrasound scan.
Correct answer: B
Rationale: The correct answer is to measure the calf circumference of both legs when assessing a patient for possible DVT. An increase in calf circumference in one leg can indicate the presence of a DVT. Option A is incorrect because dorsiflexing the foot and checking for pain are not primary assessments for DVT. Option C is incorrect as redness of the skin may not always be present in cases of DVT. Option D is incorrect as performing a Doppler ultrasound scan is usually done after clinical assessment and to confirm the diagnosis, not as the initial priority assessment.
3. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?
- A. Ensure the client is on seizure precautions.
- B. Educate the client about seizure triggers.
- C. Monitor for signs of an impending seizure.
- D. Initiate IV access for anti-seizure medication.
Correct answer: A
Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.
4. A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?
- A. Increase protein intake
- B. Monitor blood glucose levels frequently
- C. Increase the dose of insulin
- D. Reduce carbohydrate intake
Correct answer: B
Rationale: The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.
5. A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
- A. Purulent
- B. Serous
- C. Sanguineous
- D. Serosanguineous
Correct answer: D
Rationale: The correct answer is D, serosanguineous. Serosanguineous drainage is thin, watery, and pale red, indicating a mixture of serous fluid and blood. Choice A (purulent) refers to thick, yellow or green drainage indicating infection. Choice B (serous) is thin, clear drainage. Choice C (sanguineous) is bright red, indicating fresh bleeding.
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