ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse notices another nurse skipping hand hygiene. What is the appropriate course of action?
- A. Ignore the situation to maintain team harmony.
- B. Report the behavior to the supervisor.
- C. Discuss the issue with the nurse directly.
- D. Do nothing and continue with patient care.
Correct answer: B
Rationale: Correct hand hygiene is crucial for preventing the spread of infections and ensuring patient safety. When a nurse observes another healthcare worker skipping hand hygiene practices, it is essential to report this behavior to the supervisor. Reporting ensures that appropriate action is taken to address the issue and maintain a safe environment for patients. Ignoring the situation (Choice A) may compromise patient safety. Discussing the issue directly with the nurse (Choice C) may not always be effective in ensuring compliance. Doing nothing and continuing with patient care (Choice D) disregards the importance of infection control protocols.
2. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?
- A. Ensure the client is on seizure precautions.
- B. Educate the client about seizure triggers.
- C. Monitor for signs of an impending seizure.
- D. Initiate IV access for anti-seizure medication.
Correct answer: A
Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.
3. Which intervention is most effective for managing a patient with constipation?
- A. Increase the patient's fluid intake.
- B. Administer a stool softener as prescribed.
- C. Provide the patient with a high-fiber diet.
- D. Teach the patient to perform Valsalva maneuvers.
Correct answer: B
Rationale: The most effective intervention for managing constipation in a patient is to administer a stool softener as prescribed. Stool softeners help relieve constipation by making the stool easier to pass, especially in postoperative patients. Increasing fluid intake can be beneficial but may not address the underlying cause of constipation. While a high-fiber diet is important for bowel health, it may not provide immediate relief for constipation. Teaching a patient to perform Valsalva maneuvers is not recommended for managing constipation as it can lead to adverse effects like increasing intra-abdominal pressure.
4. What is the most appropriate action for handling hazardous drugs?
- A. Wear gloves and wash hands after handling.
- B. Store the drugs according to manufacturer instructions.
- C. Discard unused drugs in regular trash.
- D. Wear personal protective equipment (PPE) when handling hazardous drugs.
Correct answer: D
Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.
5. While assessing a migrant farm worker in a mobile health clinic, which of the following findings should the nurse identify as the priority?
- A. Report of back pain associated with twisting at the waist
- B. Absence of a dental health provider
- C. Lives in a home with 25 other migrant workers
- D. Report of muscle twitching and skin rash
Correct answer: D
Rationale: The correct answer is D because muscle twitching and a rash could indicate pesticide poisoning, a serious condition that requires immediate attention in a migrant farm worker. Option A is not the priority as it could be musculoskeletal in nature and managed after addressing urgent issues. Option B, absence of a dental health provider, though important for overall health, is not an immediate priority. Option C, living with 25 other migrant workers, raises concerns about living conditions but does not present an immediate health threat compared to potential pesticide poisoning.
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