ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A client has a new prescription for folic acid and believes it's only for pregnant women. What statement should the nurse make?
- A. Folic acid is important only for pregnant women.
- B. You don’t need folic acid if you eat a balanced diet.
- C. Folic acid is important for the building of blood cells for adults and children.
- D. You should take folic acid only if your blood tests show a deficiency.
Correct answer: C
Rationale: The correct answer is C because folic acid is essential for the production of red blood cells in adults and children, not just for pregnant women. Option A is incorrect as folic acid is not exclusive to pregnant women. Option B is incorrect as a balanced diet may not provide sufficient folic acid. Option D is incorrect since folic acid supplementation is also recommended for other reasons beyond deficiency.
2. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?
- A. Hypertension, bradycardia, and oliguria
- B. Bradycardia, hypertension, and peripheral edema
- C. Tachypnea, cool skin, and confusion
- D. Tachycardia, hypotension, and decreased urine output
Correct answer: D
Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.
3. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?
- A. Redness and swelling are normal after surgery
- B. Any drainage from the incision site is not concerning
- C. Yellow drainage is normal
- D. I should monitor for increased redness or warmth
Correct answer: B
Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.
4. A charge nurse is discussing HIPAA with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching as an example of a HIPAA violation?
- A. Posting the name of the nurse providing care on a client's communication board
- B. Discussing the client's new medication with a hospital pharmacist
- C. Faxing requested medical information for a client who is transferring to another facility
- D. Emailing the client's positive hepatitis results from an unencrypted server
Correct answer: D
Rationale: The correct answer is D. Emailing client information through an unencrypted server is a HIPAA violation because it can lead to data breaches. Choices A, B, and C do not violate HIPAA. Posting the name of the nurse providing care on a client's communication board does not disclose sensitive health information. Discussing the client's new medication with a hospital pharmacist is a routine healthcare practice. Faxing requested medical information for a client who is transferring to another facility is a secure way to transmit healthcare data.
5. A nurse observes a colleague not using proper hand hygiene. What should the nurse do first?
- A. Ignore the behavior and continue with care
- B. Discuss the behavior with other colleagues
- C. Confront the colleague about the behavior
- D. Report the behavior to the supervisor
Correct answer: D
Rationale: The correct action for the nurse to take first is to report the behavior to the supervisor. Proper hand hygiene is essential in preventing the spread of infections in healthcare settings. By reporting the observed behavior to the supervisor, the nurse is prioritizing patient safety and promoting a culture of accountability. Ignoring the behavior (Choice A) can put patients at risk, discussing it with other colleagues (Choice B) may not address the issue effectively, and confronting the colleague directly (Choice C) might not be the most appropriate initial step and could lead to conflicts rather than a constructive resolution.
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