ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. In a disaster where a building has collapsed, which victim should a nurse attend to first?
- A. A victim who has died of multiple serious injuries
- B. A victim with a partial amputation of a leg who is bleeding profusely
- C. An alert victim who has numerous bruises on the arms and legs
- D. A hysterical victim who has sustained a head injury
Correct answer: B
Rationale: In a disaster situation like a building collapse, the nurse should attend to the victim with a partial amputation of a leg who is bleeding profusely first. This victim is at immediate risk of severe blood loss, which can be life-threatening. It is crucial to address life-threatening injuries like severe bleeding before attending to other less urgent cases. The victim with the amputation requires immediate intervention to control bleeding and stabilize their condition. Victims who are already deceased or have less urgent injuries can be attended to after addressing the critical cases.
2. A client who has a new prescription for ferrous sulfate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect dark tarry stools.
- B. I should expect increased bruising.
- C. I will not get as many infections.
- D. I will expect the color of my urine to be amber.
Correct answer: A
Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.
3. A client has a new prescription for beclomethasone inhaler to use with an albuterol inhaler for asthma maintenance. What should the nurse instruct the client?
- A. Skip doses if breathing improves
- B. Use the albuterol inhaler first
- C. Gargle with water after each use
- D. Store inhaler in the refrigerator
Correct answer: C
Rationale: The correct answer is to instruct the client to gargle with water after each use of the beclomethasone inhaler. Beclomethasone can cause oral thrush, and gargling with water helps prevent this complication. Choice A is incorrect because the client should not skip doses even if breathing improves, as the medications are prescribed for maintenance. Choice B is incorrect as there is no specific instruction to use the albuterol inhaler first in this scenario. Choice D is incorrect because inhalers should not be stored in the refrigerator unless specified by the manufacturer.
4. A nurse is discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?
- A. To donate organs, a client must provide consent prior to death
- B. The transplant team will harvest the organs for donation from the donor client
- C. During admission, all clients over the age of 18 should be asked about their organ donor status
- D. The National Organ Transplant Act prohibits the sale and purchase of organs
Correct answer: C
Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.
5. A charge nurse is discussing HIPAA with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching as an example of a HIPAA violation?
- A. Posting the name of the nurse providing care on a client's communication board
- B. Discussing the client's new medication with a hospital pharmacist
- C. Faxing requested medical information for a client who is transferring to another facility
- D. Emailing the client's positive hepatitis results from an unencrypted server
Correct answer: D
Rationale: The correct answer is D. Emailing client information through an unencrypted server is a HIPAA violation because it can lead to data breaches. Choices A, B, and C do not violate HIPAA. Posting the name of the nurse providing care on a client's communication board does not disclose sensitive health information. Discussing the client's new medication with a hospital pharmacist is a routine healthcare practice. Faxing requested medical information for a client who is transferring to another facility is a secure way to transmit healthcare data.
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