ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A patient is experiencing shortness of breath. What is the nurse's immediate action?
- A. Assist the patient into a high Fowler's position.
- B. Administer oxygen at 2 liters per minute via nasal cannula.
- C. Encourage the patient to take deep breaths and cough.
- D. Assess the patient's lung sounds.
Correct answer: B
Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.
2. Which outcome should the nurse identify for the client diagnosed with fluid volume excess?
- A. The client will void a minimum of 30 mL per hour
- B. The client will have elastic skin turgor
- C. The client will have no adventitious breath sounds
- D. The client will have a serum creatinine of 1.4 mg/dL
Correct answer: C
Rationale: The correct outcome for a client diagnosed with fluid volume excess is the absence of adventitious breath sounds. This indicates that fluid is not accumulating in the lungs, a crucial sign in managing fluid volume excess. Choices A, B, and D are incorrect because voiding a specific amount of urine, having elastic skin turgor, and a serum creatinine level do not directly relate to managing fluid volume excess.
3. A patient who is recovering from surgery should increase their intake of which nutrient to promote healing?
- A. Fats
- B. Carbohydrates
- C. Protein
- D. Fiber
Correct answer: C
Rationale: Protein is crucial for tissue repair and recovery after surgery. Proteins provide the building blocks necessary for tissue healing and regeneration. Fats are important for various bodily functions but are not as directly involved in tissue repair as proteins. Carbohydrates provide energy but do not play a primary role in tissue healing. Fiber is essential for digestive health but is not a nutrient that directly promotes tissue repair.
4. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?
- A. Massage the client's legs every 4 hours.
- B. Administer prophylactic antibiotics.
- C. Apply sequential compression devices to the client's legs.
- D. Encourage the client to remain on bed rest.
Correct answer: C
Rationale: Applying sequential compression devices is the appropriate intervention for a client at risk for developing deep vein thrombosis (DVT). This intervention helps prevent venous stasis by promoting circulation in the lower extremities, reducing the risk of DVT. Massaging the client's legs every 4 hours is contraindicated as it can dislodge a blood clot and increase the risk of embolism. Administering prophylactic antibiotics is not indicated for preventing DVT. Encouraging the client to remain on bed rest can contribute to venous stasis and increase the risk of developing DVT.
5. Which of the following principles of primary nursing has proven most satisfying to the patient and nurse?
- A. Continuity of patient care promotes efficient and cost-effective nursing care.
- B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
- C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
- D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.
Correct answer: D
Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.
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