ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A client who has a new prescription for ferrous sulfate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect dark tarry stools.
- B. I should expect increased bruising.
- C. I will not get as many infections.
- D. I will expect the color of my urine to be amber.
Correct answer: A
Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.
2. A client is being prepared for discharge after a stroke. Which of the following interventions should be included in the discharge plan to prevent complications?
- A. Recommend physical therapy to improve mobility
- B. Teach the client how to use an incentive spirometer
- C. Encourage the client to ambulate daily
- D. Provide education on proper medication management
Correct answer: D
Rationale: The correct answer is to provide education on proper medication management. Proper medication management is crucial in reducing the risk of stroke recurrence and ensuring the client adheres to the treatment plan. While physical therapy, incentive spirometer use, and daily ambulation are important aspects of stroke rehabilitation, they are not directly related to preventing complications during the discharge phase.
3. A nurse manager is teaching a group of employees about standards for Quality and Safety Education for Nurses (QSEN). Which of the following statements by an employee should the nurse manager identify as an example of the QSEN concept of quality improvement?
- A. We should start tracking how soon clients are discharged after laparoscopic versus open surgery.
- B. We should involve our clients' partners in care planning as much as possible.
- C. We should be sure to log out of the computers immediately following documentation.
- D. We should provide change-of-shift report as a team, including the assistive personnel who assisted with care.
Correct answer: B
Rationale: Involving partners in care planning is a quality improvement strategy that aligns with QSEN principles. This choice reflects patient-centered care and collaboration, which are essential elements of quality improvement. Choices A, C, and D do not directly relate to quality improvement concepts. Tracking discharge times, logging out of computers, and providing change-of-shift reports are important practices but not specifically focused on quality improvement.
4. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?
- A. Suction the tracheostomy to maintain a patent airway.
- B. Administer pain medication as prescribed.
- C. Change the tracheostomy dressing every 4 hours.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.
5. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?
- A. Measure and document the urine in the drainage bag
- B. Remove the tape or device securing the catheter to the client's thigh
- C. Position the client supine
- D. Deflate the catheter balloon using a sterile syringe
Correct answer: A
Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.
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