ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?
- A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
- B. Advance the stronger leg and the cane together to support the weaker leg
- C. Remove the rubber tip when using the cane
- D. Hold the cane on the right side to provide support for the weaker leg
Correct answer: D
Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.
2. A county public health nurse is developing a list of interventions to address the three core functions of public health. Which of the following interventions should the nurse include as part of the assurance function?
- A. Use surveillance to investigate outbreaks of foodborne illness
- B. Monitor the incidence rates of varicella every 2 months
- C. Organize an immunization clinic for at-risk members of the community
- D. Educate the community about the health risks of alcohol use
Correct answer: C
Rationale: The correct answer is C: 'Organize an immunization clinic for at-risk members of the community.' This intervention is part of the assurance function in public health, as it ensures that the community has access to preventive health services. Choice A is related to the assessment function as it involves surveillance to investigate outbreaks. Choice B is also related to the assessment function since it involves monitoring incidence rates. Choice D is associated with the policy development function as it involves educating the community about health risks.
3. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?
- A. Crush all medications and administer them all at once.
- B. Flush the NG tube before and after each medication.
- C. Administer only liquid forms of medications.
- D. Skip flushing the tube entirely.
Correct answer: B
Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.
4. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?
- A. Place the call light within the patient's reach.
- B. Apply a yellow fall risk bracelet to the patient.
- C. Assist the patient when ambulating.
- D. Ensure the patient's room is well-lit.
Correct answer: B
Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.
5. Which intervention should be prioritized for a client experiencing panic-level anxiety?
- A. Postpone health teaching until anxiety subsides
- B. Encourage participation in group therapy
- C. Monitor vital signs every 5 minutes
- D. Provide reassurance and remain with the client
Correct answer: D
Rationale: During panic-level anxiety, the priority is to provide reassurance and remain with the client. This intervention helps to offer immediate support, comfort, and a sense of safety to the client. Postponing health teaching until anxiety subsides (Choice A) is not appropriate as the client's immediate emotional needs are more critical. Encouraging participation in group therapy (Choice B) may be beneficial in the long term but is not the priority during a panic attack. While monitoring vital signs (Choice C) is important, providing reassurance and support take precedence in managing panic-level anxiety.
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