ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. 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.
2. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
- A. Hold the cane with your left hand
- B. Move the cane forward 18 inches with each step
- C. When walking, move your left foot forward first
- D. Keep your elbow straight when you hold the cane
Correct answer: C
Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.
3. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?
- A. Brachial pulse in the right arm
- B. Radial pulse in the right arm
- C. Brachial pulse in the left arm
- D. Radial pulse in the left arm
Correct answer: D
Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.
4. A client with pneumonia is receiving oxygen therapy. Which of the following oxygen delivery devices should be used to deliver a precise oxygen concentration?
- A. Nasal cannula
- B. Simple face mask
- C. Venturi mask
- D. Non-rebreather mask
Correct answer: C
Rationale: A Venturi mask should be used to deliver a precise oxygen concentration to a client with pneumonia. Venturi masks are designed to deliver a specific oxygen concentration by mixing oxygen with room air in a precise ratio. This device is ideal for patients who require accurate oxygen delivery, such as those with chronic lung diseases. Nasal cannulas deliver a lower concentration of oxygen and are more suitable for patients with mild respiratory issues. Simple face masks and non-rebreather masks do not provide as precise control over the oxygen concentration as a Venturi mask.
5. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?
- A. Apply a dry, sterile dressing to the wound.
- B. Use sterile saline to clean the wound.
- C. Apply a warm compress to promote circulation.
- D. Keep the wound open to air for faster healing.
Correct answer: B
Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.
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