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. What are the nursing considerations when caring for a patient with chronic obstructive pulmonary disease (COPD)?
- A. Encouraging pursed-lip breathing to improve ventilation
- B. Administering bronchodilators and corticosteroids
- C. Monitoring oxygen saturation and ABGs
- D. Teaching the patient how to use an inhaler
Correct answer: A
Rationale: The correct answer is A. Pursed-lip breathing is a nursing consideration for patients with COPD as it helps improve oxygenation and reduces air trapping. While administering bronchodilators and corticosteroids (choice B) is part of the treatment plan, it is typically done by healthcare providers. Monitoring oxygen saturation and arterial blood gases (ABGs) (choice C) is important but not a direct nursing consideration. Teaching the patient how to use an inhaler (choice D) is relevant but not specific to COPD care.
3. A nurse is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer?
- A. 1
- B. 2
- C. 3
- D. 4
Correct answer: B
Rationale: The correct answer is B: 2. To achieve the prescribed dose of 0.25 mg of digoxin, the nurse should administer two 0.125 mg tablets. This calculation ensures that the patient receives the correct amount of medication. Choices A, C, and D are incorrect because they do not reflect the accurate dosage needed based on the available tablets and prescribed dose.
4. A healthcare provider is assessing a patient with dehydration. Which finding indicates the patient's condition is worsening?
- A. Dry mucous membranes.
- B. Tachycardia and low blood pressure.
- C. Bradycardia and shallow respirations.
- D. Clear lung sounds.
Correct answer: B
Rationale: Tachycardia and low blood pressure are indicative of worsening dehydration in a patient. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased intravascular volume, while low blood pressure reflects inadequate perfusion due to decreased fluid levels. Bradycardia and shallow respirations are not typical findings in worsening dehydration, and clear lung sounds do not directly correlate with the severity of dehydration.
5. A forensic nurse is using the epidemiological triangle to explain factors that contribute to violent behavior. Which of the following factors should the nurse identify as an environmental factor in the epidemiological triangle?
- A. Crowded living conditions
- B. Traumatic brain injury
- C. Alzheimer's disease
- D. Impaired coping abilities
Correct answer: A
Rationale: Crowded living conditions are considered an environmental factor in the epidemiological triangle as they can contribute to the spread of violence. In this context, environmental factors refer to external influences such as social and physical environments. Traumatic brain injury, Alzheimer's disease, and impaired coping abilities are not typically classified as environmental factors in the epidemiological triangle. Traumatic brain injury and Alzheimer's disease are more related to individual health conditions, while impaired coping abilities are more focused on individual psychological factors rather than external environmental influences.
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