ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A client has a new prescription for guaifenesin. What information regarding the action of guaifenesin should the nurse include in the teaching?
- A. Decreases mucus production
- B. Reduces nasal congestion
- C. Increases cough production
- D. Reduces fever
Correct answer: C
Rationale: The correct answer is C: 'Increases cough production.' Guaifenesin is an expectorant that works by increasing cough production to help clear secretions from the airways. Option A is incorrect because guaifenesin does not decrease mucus production but rather helps to make the mucus easier to cough up. Option B is incorrect as guaifenesin does not reduce nasal congestion. Option D is incorrect because guaifenesin does not have any effect on reducing fever.
2. A client with a DNR order has requested resuscitation during a visit from the family. What is the nurse's best course of action?
- A. Follow the family's request and perform CPR.
- B. Explain to the family that the DNR must be honored.
- C. Call the healthcare provider to cancel the DNR order.
- D. Delay resuscitation until further clarification can be made.
Correct answer: B
Rationale: The correct course of action for the nurse is to explain to the family that the DNR (Do Not Resuscitate) order must be honored. It is essential for the nurse to uphold the client's wishes as documented in the DNR order. Performing CPR against the client's expressed wishes in the DNR order would violate ethical and legal standards. Calling the healthcare provider to cancel the DNR order without the client's consent is inappropriate and goes against the client's autonomy. Delaying resuscitation can be detrimental in an emergency situation and may not align with the client's wishes as outlined in the DNR order.
3. A client has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent infection?
- A. Change the catheter every 72 hours.
- B. Ensure the tubing is unkinked.
- C. Empty the drainage bag every 4 hours.
- D. Hang the drainage bag below the bladder.
Correct answer: D
Rationale: The correct answer is to hang the drainage bag below the bladder. This positioning helps prevent backflow of urine, reducing the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may increase infection risk by introducing pathogens. Ensuring the tubing is unkinked promotes proper urine flow but does not directly prevent infection. Emptying the drainage bag regularly is important to prevent urinary stasis but does not directly address infection prevention.
4. A client is undergoing chemotherapy and expresses concern about hair loss. What is the best response?
- A. Reassure the client that hair loss is not permanent.
- B. Provide resources for wigs or hairpieces.
- C. Encourage the client to cut their hair short in advance.
- D. Advise the client that chemotherapy causes temporary hair loss.
Correct answer: D
Rationale: The best response when a client undergoing chemotherapy expresses concern about hair loss is to advise them that chemotherapy causes temporary hair loss. This response provides accurate information to the client about the side effect they are experiencing. Choice A is incorrect because it may provide false reassurance as for some individuals, hair loss can be a challenging experience. Choice B is not the best initial response as addressing the client's concerns and providing information should come first. Choice C is not the most appropriate response as cutting hair short may not necessarily prevent hair loss and does not address the client's concerns about the temporary nature of chemotherapy-induced hair loss.
5. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
- A. Discontinue current medications
- B. Write new prescriptions
- C. Compare prescriptions with the client’s medications
- D. Ask the client to decide
Correct answer: C
Rationale: The correct action in the medication reconciliation process is to compare prescriptions with the client’s medications. This step ensures that there are no conflicting medications prescribed, reducing the risk of adverse drug interactions. Discontinuing current medications or writing new prescriptions without comparing them can lead to errors and potential harm. Asking the client to decide is not appropriate in this context as it is the nurse's responsibility to ensure medication safety based on professional judgment and knowledge.
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