ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?
- A. Change IV solution bags every 36 hr.
- B. Avoid the delegation of hygiene care to assistive personnel (AP)
- C. Wear sterile gloves when removing urinary retention catheters.
- D. Educate staff about the correct use of personal protective equipment (PPE) for isolation precautions
Correct answer: D
Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.
2. A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?
- A. Give detailed information about the medication, including its potential side effects.
- B. Refer the client to the healthcare provider for more information.
- C. Give a brief explanation and administer the medication.
- D. Ask another nurse to explain the medication and proceed.
Correct answer: B
Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.
3. When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?
- A. Check for respiratory depression.
- B. Assess pain control.
- C. Check the infusion site for complications.
- D. Monitor the client's blood pressure.
Correct answer: A
Rationale: The correct answer is to check for respiratory depression first when assessing a client receiving a continuous intravenous infusion of morphine sulfate. Respiratory depression is the most common life-threatening side effect associated with morphine administration. Monitoring respiratory status is crucial as it can quickly deteriorate, leading to serious complications or even respiratory arrest. Assessing pain control (choice B) is important but ensuring adequate ventilation takes precedence. Checking the infusion site for complications (choice C) and monitoring blood pressure (choice D) are also essential aspects of care but are secondary to evaluating respiratory status when administering morphine.
4. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?
- A. Monitor the patient's vital signs.
- B. Check the patient's weight daily.
- C. Measure the patient's intake and output.
- D. Monitor the patient's urine color.
Correct answer: B
Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.
5. Which intervention reduces reservoirs of infection in a healthcare setting?
- A. Placing capped needles and syringes in puncture-resistant containers
- B. Keeping bedside table surfaces clean and dry
- C. Changing dressings that become wet or soiled
- D. Placing tissues and soiled dressings in paper bags
Correct answer: A
Rationale: Placing capped needles and syringes in puncture-resistant containers is the correct intervention to reduce infection reservoirs in healthcare settings. This practice helps prevent accidental needle-stick injuries and contains potentially infectious materials properly. Keeping bedside table surfaces clean and dry (choice B) is essential for preventing the spread of infections but does not directly address reducing reservoirs of infection. Changing dressings that become wet or soiled (choice C) is important for wound care but does not specifically target infection reservoirs. Placing tissues and soiled dressings in paper bags (choice D) is a proper waste disposal practice but does not directly reduce reservoirs of infection in a healthcare setting.
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