ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A parent of a child who is terminally ill tells a nurse that she wants to take her child home. Which of the following responses should the nurse make?
- A. Your provider will be here later today.
- B. I can give you information on what that would involve.
- C. I understand how you feel. I felt the same way when my sister was terminally ill.
- D. I think you should speak with social services about your request.
Correct answer: B
Rationale: The nurse should offer to explain the process of taking the child home and provide resources for the parent's decision. Choice B is the best response as it shows willingness to support the parent by offering information on what taking the child home would involve. Choices A, C, and D do not directly address the parent's request or provide the necessary information and support needed in this situation.
2. A nurse is providing discharge teaching for a client prescribed warfarin. What should be included in the teaching?
- A. Avoid foods rich in vitamin K
- B. Take warfarin with meals
- C. Take aspirin for pain relief
- D. Report unusual bleeding or bruising
Correct answer: D
Rationale: The correct answer is D. When a client is prescribed warfarin, they should be educated to report any unusual bleeding or bruising promptly. Choices A, B, and C are incorrect. Avoiding foods rich in vitamin K is not necessary when taking warfarin, as long as intake remains consistent. Warfarin does not need to be taken with meals, and aspirin should not be taken for pain relief due to its blood-thinning effects, which can increase the risk of bleeding when combined with warfarin.
3. 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.
4. What are the important considerations when administering blood products to a patient?
- A. Ensuring proper documentation of the transfusion
- B. Verifying the patient's identity before administration
- C. Monitoring for allergic reactions or transfusion reactions
- D. Monitoring the patient's vital signs during transfusion
Correct answer: B
Rationale: Verifying the patient's identity before administration is a critical step to ensure that the correct blood product is given to the right patient, thereby preventing transfusion errors. While ensuring proper documentation of the transfusion (choice A) is important for record-keeping, verifying patient identity (choice B) directly addresses the risk of administering blood to the wrong patient. Monitoring for allergic reactions or transfusion reactions (choice C) and monitoring the patient's vital signs during transfusion (choice D) are also essential considerations during blood product administration, but verifying patient identity takes precedence to prevent potentially life-threatening errors.
5. A healthcare professional is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the healthcare professional place at the client's bedside?
- A. Defibrillator machine
- B. Chest tube equipment
- C. Central venous catheter tray
- D. Bag-valve-mask device
Correct answer: D
Rationale: Corrected Rationale: A bag-valve-mask device is necessary in case of respiratory complications that may arise due to the effects of the neuromuscular blocking agent. The competitive nature of the agent can lead to muscle weakness, including respiratory muscles, necessitating immediate respiratory support. Placing a defibrillator machine, chest tube equipment, or central venous catheter tray at the client's bedside would not be the priority in this situation. While these items may be important in specific scenarios, ensuring the availability of a bag-valve-mask device is crucial to address potential airway and breathing issues promptly.
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