ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?
- A. Confront the nurse about the behavior.
- B. Notify the hospital's safety committee.
- C. Document the observation without addressing it.
- D. Follow up with the nurse at a later time.
Correct answer: B
Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.
2. The client is on furosemide (Lasix) and has a potassium level of 2.9 mEq/L. What is the nurse’s priority action?
- A. Administer potassium supplements.
- B. Hold the furosemide and notify the healthcare provider.
- C. Continue the current dose of furosemide.
- D. Decrease the dose of furosemide.
Correct answer: A
Rationale: The correct answer is A: Administer potassium supplements. A potassium level of 2.9 mEq/L indicates hypokalemia (low potassium levels). Furosemide (Lasix) is a loop diuretic that can cause potassium loss. Therefore, the priority action is to administer potassium supplements to correct the imbalance. Option B is incorrect because holding the furosemide without addressing the low potassium level could further worsen the imbalance. Option C is incorrect as continuing the current dose of furosemide without addressing the low potassium level could lead to complications. Option D is incorrect because decreasing the dose of furosemide does not directly address the low potassium level that needs immediate correction.
3. A client is prescribed levothyroxine for hypothyroidism. Which of the following findings should indicate to the nurse that the medication is effective?
- A. Decreased heart rate
- B. Increased energy levels
- C. Weight loss
- D. Improved mental clarity
Correct answer: B
Rationale: Increased energy levels are a key indicator of the effectiveness of levothyroxine in treating hypothyroidism. Levothyroxine works to regulate thyroid hormone levels, which can lead to improved energy levels as the body's metabolism is restored. While the other options may also improve with treatment, increased energy levels directly reflect the correction of the thyroid hormone imbalance. Decreased heart rate can be an indicator of overmedication, weight loss can be attributed to increased metabolism but may not directly reflect the effectiveness of levothyroxine, and improved mental clarity is a more general cognitive improvement that may not directly relate to thyroid function.
4. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?
- A. Retake the temperature in 15 minutes after giving the Tylenol.
- B. Place a warm blanket on the child so chilling does not occur.
- C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
- D. Use cold compresses instead of Tylenol to control the fever.
Correct answer: C
Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.
5. What is the priority intervention for a patient with dehydration?
- A. Administer IV fluids
- B. Monitor intake and output
- C. Administer oral fluids
- D. Provide electrolyte replacement
Correct answer: A
Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.
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