ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A nurse manager is teaching a group of staff members about proper body mechanics. Which of the following statements by a staff member indicates an understanding of the teaching?
- A. I should get assistance when lifting more than 35 pounds
- B. I will twist at my waist when moving an object
- C. I should hold objects 1 ft away from my body when I walk
- D. I will roll my shoulders forward to reduce strain on my back
Correct answer: A
Rationale: Choice A is the correct answer because lifting more than 35 pounds without assistance can cause injury, so getting help is crucial for proper body mechanics. Choice B is incorrect as twisting at the waist can lead to back injuries. Choice C is incorrect as holding objects closer to the body, not 1 ft away, is recommended to reduce strain. Choice D is incorrect as rolling shoulders forward can increase strain on the back instead of reducing it.
2. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
- A. Self-report of pain
- B. Nonverbal behavior
- C. Severity of the condition
- D. Vital signs
Correct answer: A
Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.
3. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy.
- B. Provide resources for wigs or hairpieces.
- C. Assure the client that hair loss will be minimal.
- D. Offer the client medication to reduce the chances of hair loss.
Correct answer: B
Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.
4. A patient with a history of asthma is admitted with shortness of breath. What is the nurse's priority intervention?
- A. Administer a bronchodilator as prescribed.
- B. Encourage the patient to use an incentive spirometer.
- C. Place the patient in a high Fowler's position.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to administer a bronchodilator as prescribed. This intervention is the priority for a patient with asthma experiencing shortness of breath as it helps relax the airways, making breathing easier. Encouraging the use of an incentive spirometer (Choice B) is beneficial for lung expansion but not the priority in this acute situation. Placing the patient in a high Fowler's position (Choice C) can also help with breathing but is not as immediate as administering a bronchodilator. While monitoring the patient's oxygen saturation closely (Choice D) is important, the immediate action to address the breathing difficulty is administering a bronchodilator.
5. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?
- A. Bend at the waist when picking up objects.
- B. Avoid lying on the operative side.
- C. Avoid lifting more than 10 lb.
- D. Apply ice to the affected eye.
Correct answer: C
Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.
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