ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?
- A. Wear gloves when entering the patient's room.
- B. Place the patient in a private room.
- C. Use a dedicated blood pressure cuff for the patient.
- D. Dispose of all equipment in a biohazard bag.
Correct answer: A
Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.
2. A nurse is teaching a female client who is experiencing alcohol withdrawal about chlordiazepoxide. Which of the following information should the nurse include in the teaching?
- A. This medication may increase your blood pressure
- B. Breast tenderness may occur with this medication
- C. You can double the dose of medication if you feel anxious
- D. Notify the provider if pregnancy is desired or suspected
Correct answer: D
Rationale: Pregnancy can complicate alcohol withdrawal treatment, and the provider should be notified.
3. How should a healthcare provider respond when a patient expresses concerns about the side effects of a prescribed medication?
- A. Reassure the patient that side effects are rare.
- B. Discuss the benefits and risks of the medication with the patient.
- C. Encourage the patient to speak to the pharmacist.
- D. Refer the patient to another healthcare provider for information.
Correct answer: B
Rationale: When a patient expresses concerns about medication side effects, it is crucial for the healthcare provider to discuss the benefits and risks of the medication with the patient. This approach helps the patient make an informed decision about their treatment. Choice A is incorrect because dismissing the patient's concerns by reassuring them that side effects are rare may not address the patient's specific worries. Choice C, while pharmacists can provide valuable information, the primary responsibility lies with the healthcare provider. Choice D is incorrect as referring the patient to another healthcare provider may disrupt continuity of care and not address the patient's concerns effectively.
4. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy.
- B. Provide resources for wigs or hairpieces.
- C. Assure the client that hair loss will be minimal.
- D. Offer the client medication to reduce the chances of hair loss.
Correct answer: B
Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.
5. What intervention should the nurse implement for a patient receiving a blood transfusion?
- A. Administer antihistamines to prevent allergic reactions.
- B. Monitor the patient for signs of circulatory overload.
- C. Ensure the blood transfusion is completed within 4 hours.
- D. Check the patient's vital signs every 30 minutes during the transfusion.
Correct answer: B
Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.
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