ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse sees a healthcare provider administer an incorrect medication dose but does not report the error. What should the nurse do first?
- A. Ignore the situation and continue with patient care.
- B. Report the error to the nurse manager immediately.
- C. Speak to the healthcare provider directly about the error.
- D. File an anonymous report to avoid conflict.
Correct answer: B
Rationale: When a nurse witnesses a healthcare provider administering an incorrect medication dose, the first step should be to report the error to the nurse manager immediately. Reporting medication errors is crucial for patient safety as it allows prompt intervention to prevent harm. Choice A is incorrect as ignoring the situation can jeopardize patient safety. Choice C, while addressing the error directly, may not ensure proper documentation and follow-up. Choice D, filing an anonymous report, is not as effective as directly informing the nurse manager who can take appropriate action and follow-up on the incident.
2. A nurse sees another nurse administering medication without using alcohol swabs. What is the first action the nurse should take?
- A. Ignore the situation to maintain a good working relationship.
- B. Report the behavior to the nurse manager.
- C. Ask the colleague to be more careful next time.
- D. Report the issue after speaking to other colleagues.
Correct answer: B
Rationale: The correct action for the nurse to take when witnessing unsafe medication administration practices, such as not using alcohol swabs, is to report the behavior to the nurse manager immediately. Patient safety is the top priority, and any actions that compromise it must be addressed promptly. Ignoring the situation (Choice A) is not appropriate as it puts patients at risk. Asking the colleague to be more careful (Choice C) may not be effective in ensuring immediate correction of the unsafe practice. Reporting the issue after speaking to other colleagues (Choice D) delays necessary action and may compromise patient safety further.
3. When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?
- A. Proceed with the surgery and document the refusal.
- B. Ask the patient for permission to secure the jewelry safely.
- C. Tape the jewelry to the patient's body during surgery.
- D. Tell the patient they must remove the jewelry for safety reasons.
Correct answer: B
Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.
4. 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.
5. A nurse is assigned to care for a client with unstable blood pressure. What should the nurse do first?
- A. Monitor the client every two hours.
- B. Continuously monitor the client's vital signs.
- C. Wait for the healthcare provider to provide instructions.
- D. Ask the healthcare provider for specific instructions.
Correct answer: B
Rationale: In the case of a client with unstable blood pressure, the priority action for the nurse is to continuously monitor the client's vital signs. This allows for immediate detection of any fluctuations in blood pressure and timely intervention if necessary. Choice A, monitoring every two hours, may not provide real-time information needed for prompt intervention. Choices C and D suggest waiting for instructions from the healthcare provider, which could cause a delay in addressing the unstable blood pressure, potentially leading to adverse outcomes. Therefore, the most appropriate initial action is to continuously monitor the client's vital signs.
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