ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is teaching a female client who is experiencing alcohol withdrawal about chlordiazepoxide. Which of the following information should the nurse include in the teaching?
- A. This medication may increase your blood pressure
- B. Breast tenderness may occur with this medication
- C. You can double the dose of medication if you feel anxious
- D. Notify the provider if pregnancy is desired or suspected
Correct answer: D
Rationale: Pregnancy can complicate alcohol withdrawal treatment, and the provider should be notified.
2. A healthcare professional is preparing to administer an intravenous (IV) medication. What action should the healthcare professional take to ensure patient safety?
- A. Ensure the medication is administered at the correct time.
- B. Verify the patient's identification using two identifiers.
- C. Prepare the medication at the healthcare professional's station.
- D. Ensure the medication is administered within 30 minutes of the scheduled time.
Correct answer: B
Rationale: Verifying the patient's identity using two identifiers is crucial to ensure the right patient receives the right medication. This process helps prevent medication errors by confirming the patient's identity through at least two unique identifiers, such as name, date of birth, or medical record number. Choice A is not directly related to ensuring patient safety during medication administration. Choice C is incorrect as medications should be prepared in a sterile environment, not just at the healthcare professional's station. Choice D is not a safe practice as medications should be administered at the scheduled time to maintain therapeutic effectiveness.
3. A nurse in an emergency department is preparing a change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report?
- A. The client has a do-not-resuscitate order.
- B. The client has a continuous IV of lactated Ringer's.
- C. The client was straight catheterized for 350 mL 2 hours ago.
- D. The client has Medicare insurance.
Correct answer: A
Rationale: In an SBAR report, key information such as the client's do-not-resuscitate (DNR) status should be included as it directly impacts the client's care and treatment plan. Choices B and C are important details but may not be as critical for immediate care planning during the shift change. Choice D, the client having Medicare insurance, is important for billing purposes but does not directly impact the client's immediate care needs.
4. A nurse is providing discharge teaching for a client prescribed warfarin. What should be included in the teaching?
- A. Avoid foods rich in vitamin K
- B. Take warfarin with meals
- C. Take aspirin for pain relief
- D. Report unusual bleeding or bruising
Correct answer: D
Rationale: The correct answer is D. When a client is prescribed warfarin, they should be educated to report any unusual bleeding or bruising promptly. Choices A, B, and C are incorrect. Avoiding foods rich in vitamin K is not necessary when taking warfarin, as long as intake remains consistent. Warfarin does not need to be taken with meals, and aspirin should not be taken for pain relief due to its blood-thinning effects, which can increase the risk of bleeding when combined with warfarin.
5. A healthcare professional is giving a change-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is the priority for the healthcare professional to provide?
- A. Recent chest x-ray results
- B. Medication history
- C. Breath sounds
- D. Lab results
Correct answer: C
Rationale: The correct answer is C: 'Breath sounds.' When providing a change-of-shift report for a client with pneumonia, the priority information to communicate is the assessment of breath sounds. Monitoring breath sounds is crucial in assessing respiratory status and the effectiveness of treatments in pneumonia. Option A, recent chest x-ray results, may be important but does not provide real-time information on the client's current status. Option B, medication history, is relevant but not as immediate as assessing breath sounds. Option D, lab results, can provide valuable information but may not be as urgent as monitoring the client's respiratory status through breath sounds.
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