a nurse is reviewing the notes written by a previous shift which documentation reflects proper guidelines
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A healthcare professional is reviewing the notes written by a previous shift. Which documentation reflects proper guidelines?

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.

2. A nurse at a provider's office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (SATA)

Correct answer: A

Rationale: Topping fruits with yogurt is the correct recommendation to increase calorie and protein intake for a client on chemotherapy who is losing weight. Yogurt is a good source of protein and adding it to fruits can provide additional calories as well. Choice B, adding cream to soups, may increase calorie intake but does not specifically address protein needs. Choice C, increasing fluids during meals, is important for hydration but does not directly address calorie and protein intake. Choice D, using milk instead of water in recipes, may increase calorie content but does not focus on increasing protein intake, which is essential for clients on chemotherapy.

3. When working with a client who does not speak the same language, which of the following actions should the nurse take?

Correct answer: C

Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.

4. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?

Correct answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

5. Which of the following statements reflects the principles of sterile technique?

Correct answer: A

Rationale: The correct statement reflecting the principles of sterile technique is that sterile objects that come in contact with unsterile objects are considered contaminated. This principle is crucial in maintaining asepsis during medical procedures. Choice B is incorrect because items in a sterile package should only be used if they remain sterile; opening the package does not automatically contaminate the items. Choice C is incorrect as any part of a sterile field that hangs below the top of the table is considered unsterile. Choice D is incorrect as the edge of a sterile field and a border inward are typically considered unsterile to maintain the integrity of the sterile area.

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