ATI RN
ATI Capstone Comprehensive Assessment B
1. A nursing instructor is observing a nursing student practicing standard precautions. Which observation by the instructor indicates a need for further teaching?
- A. The nursing student wears a gown to change the bed of an incontinent client.
- B. The nursing student washes hands before making contact with the client.
- C. The nursing student washes her hands before glove removal after emptying a Foley bag.
- D. The nursing student changes gloves between tasks and procedures.
Correct answer: C
Rationale: The correct answer is C. The nursing student washing her hands before glove removal after emptying a Foley bag indicates a need for further teaching. Hands should be washed after glove removal to maintain proper infection control. Choice A is correct as wearing a gown when changing the bed of an incontinent client is a standard precaution. Choice B is correct as washing hands before making contact with the client is a good practice. Choice D is correct as changing gloves between tasks and procedures is a standard precaution to prevent the spread of infection.
2. Nurse Meredith is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
- A. at the end of her menstrual cycle.
- B. on the same day each month.
- C. on the 1st day of the menstrual cycle.
- D. immediately after her menstrual period.
Correct answer: D
Rationale: For premenopausal women, the best time to perform a breast self-examination (BSE) is immediately after their menstrual period ends. This timing is ideal because hormonal fluctuations during the menstrual cycle can cause breast tissue to become swollen and tender, making it more difficult to detect any lumps or changes. After the menstrual period, breast tissue is usually softer and less lumpy, allowing for a more accurate assessment of any abnormalities.
3. A client prescribed home oxygen therapy is receiving discharge teaching from a nurse. Which statement by the client indicates a need for further teaching?
- A. I will be able to tell the amount of oxygen being delivered by looking at the flowmeter.
- B. I should contact my doctor if I notice a decrease in my ability to concentrate.
- C. I will ensure that visitors smoke outside.
- D. I should see a frosty buildup on the tank when I refill my portable oxygen.
Correct answer: A: "I will be able to tell the amount of oxygen being delivered by looking at the flowmeter."
Rationale: The correct answer is A. The client's statement indicates a need for further teaching because the flowmeter indicates the flow rate of oxygen, not the total amount of oxygen being delivered. Choices B, C, and D demonstrate understanding of safety measures and indications for seeking medical attention in relation to home oxygen therapy, making them appropriate statements.
4. A nurse at a provider's office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (SATA)
- A. Top fruits with yogurt
- B. Add cream to soups
- C. Increase fluids during meals
- D. Use milk instead of water in recipes
Correct answer: A
Rationale: Topping fruits with yogurt is the correct recommendation to increase calorie and protein intake for a client on chemotherapy who is losing weight. Yogurt is a good source of protein and adding it to fruits can provide additional calories as well. Choice B, adding cream to soups, may increase calorie intake but does not specifically address protein needs. Choice C, increasing fluids during meals, is important for hydration but does not directly address calorie and protein intake. Choice D, using milk instead of water in recipes, may increase calorie content but does not focus on increasing protein intake, which is essential for clients on chemotherapy.
5. What is the best position for a patient experiencing shortness of breath?
- A. Supine position
- B. Semi-Fowler's position
- C. Trendelenburg position
- D. Prone position
Correct answer: B
Rationale: The best position for a patient experiencing shortness of breath is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Supine position (lying flat on the back) may worsen breathing difficulties by reducing lung capacity. The Trendelenburg position (feet elevated higher than the head) is not recommended for patients with shortness of breath as it can increase pressure on the diaphragm and compromise breathing. The Prone position (lying face down) is also not suitable for patients experiencing shortness of breath as it may further restrict breathing.
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