ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?
- A. Apply a dressing to the ulcer.
- B. Reposition the patient every 2 hours.
- C. Provide the patient with pain medication.
- D. Clean the ulcer with normal saline.
Correct answer: B
Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.
2. While reviewing a client's chart, a nurse notices a discrepancy in the medication record. What should the nurse do?
- A. Correct the discrepancy and document the correction.
- B. Report the discrepancy to the nurse manager.
- C. Ignore the discrepancy assuming it is a clerical error.
- D. Discuss the discrepancy with the client and adjust the records.
Correct answer: B
Rationale: Reporting medication discrepancies to the nurse manager is crucial to ensure patient safety and proper follow-up. The nurse manager is responsible for addressing medication errors and implementing necessary corrective actions. Choice A is incorrect because simply correcting the discrepancy without reporting it may lead to potential harm to the patient and violates professional standards. Choice C is incorrect as ignoring the discrepancy increases the risk of medication errors going unresolved. Choice D is incorrect because discussing the discrepancy with the client before verifying the accuracy of the record can cause confusion and compromise patient safety.
3. Which of the following is a primary focus of tertiary prevention in mental health?
- A. Identifying early signs of mental illness
- B. Preventing the occurrence of mental health problems
- C. Rehabilitation and prevention of further deterioration
- D. Providing a safe environment to prevent harm
Correct answer: C
Rationale: The correct answer is C: Rehabilitation and prevention of further deterioration. Tertiary prevention in mental health aims to provide interventions and support to individuals who already have a mental illness to prevent further deterioration and promote recovery. Choice A, identifying early signs of mental illness, is more aligned with primary prevention which focuses on preventing the onset of mental health problems. Choice B, preventing the occurrence of mental health problems, pertains to secondary prevention which involves early detection and intervention to prevent the progression of mental health issues. Choice D, providing a safe environment to prevent harm, is important but it is not the primary focus of tertiary prevention which is more centered on rehabilitation and improving the quality of life for individuals with existing mental health conditions.
4. A patient has a DNR (do-not-resuscitate) order but their family insists on resuscitation if necessary. What should the nurse do?
- A. Follow the family's wishes to resuscitate.
- B. Explain that the nurse must follow the DNR order.
- C. Ask the provider for clarification on the DNR.
- D. Call the ethics committee to discuss the situation.
Correct answer: B
Rationale: The correct answer is B. The nurse must follow the legal DNR order, even if the family insists on resuscitation. Respecting the patient's wishes is crucial in providing ethical care. Choice A is incorrect because the nurse should prioritize the patient's documented wishes over the family's requests. Choice C may cause unnecessary delays in care as the DNR order is a legal document. Choice D is not the initial action to take in this situation; the nurse should first address the conflict between the family's wishes and the patient's DNR order.
5. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
- A. Discontinue current medications
- B. Write new prescriptions
- C. Compare prescriptions with the client’s medications
- D. Ask the client to decide
Correct answer: C
Rationale: The correct action in the medication reconciliation process is to compare prescriptions with the client’s medications. This step ensures that there are no conflicting medications prescribed, reducing the risk of adverse drug interactions. Discontinuing current medications or writing new prescriptions without comparing them can lead to errors and potential harm. Asking the client to decide is not appropriate in this context as it is the nurse's responsibility to ensure medication safety based on professional judgment and knowledge.
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