ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?
- A. Administer acetaminophen
- B. Stop the transfusion
- C. Slow the transfusion rate
- D. Administer antihistamines
Correct answer: B
Rationale: The correct answer is to stop the transfusion (Choice B). The symptoms described - chills, headache, and low back pain - are indicative of a transfusion reaction. The priority action is to immediately stop the transfusion to prevent further complications such as more severe reactions like hemolytic reactions or anaphylaxis. Administering acetaminophen (Choice A) may help with symptoms but does not address the underlying cause. Slowing the transfusion rate (Choice C) may not be sufficient if a serious transfusion reaction is occurring. Administering antihistamines (Choice D) is not the priority in this situation; stopping the transfusion takes precedence to ensure patient safety.
2. A nurse is caring for a client who has chronic kidney disease and a serum potassium level of 6.0 mEq/L. Which of the following findings should the nurse expect?
- A. Hypokalemia
- B. Hypocalcemia
- C. Hypoglycemia
- D. Hyperkalemia
Correct answer: D
Rationale: The correct answer is D: Hyperkalemia. In chronic kidney disease, there is decreased renal excretion of potassium, leading to elevated serum potassium levels. Hypokalemia (Choice A) is low potassium levels, which is the opposite finding in this scenario. Hypocalcemia (Choice B) is decreased calcium levels and is not directly related to chronic kidney disease or elevated potassium levels. Hypoglycemia (Choice C) is low blood sugar levels and is not typically associated with chronic kidney disease or high potassium levels.
3. Despite growing up in a rundown neighborhood, having divorced parents, and rarely seeing her father, Betty is a successful, happy, and healthy adult. Betty's ability to adapt effectively in the face of threats to development is known as __________.
- A. assimilation
- B. resilience
- C. age-graded development
- D. multidimensional development
Correct answer: B
Rationale: Betty's ability to adapt effectively despite facing challenges during her childhood such as growing up in a rundown neighborhood, having divorced parents, and rarely seeing her father demonstrates resilience. Resilience refers to the capacity to achieve positive outcomes despite adverse circumstances. Betty's successful, happy, and healthy adulthood showcases her resilience in navigating and overcoming the threats to her development. Choice A, assimilation, does not fit the context of adapting effectively to adverse circumstances. Assimilation is a cognitive process related to incorporating new information into existing schemas. Choice C, age-graded development, refers to typical developmental changes that occur in a culture at a particular age. Choice D, multidimensional development, encompasses the idea that development is influenced by multiple factors across various dimensions, which is not directly related to Betty's ability to adapt effectively despite facing challenges.
4. A patient tells the nurse “I am depressed to talk to you, leave me alone†Which of the following response by the nurse is most therapeutic?
- A. I’ll be back in an hour
- B. Why are you so depressed?
- C. I’ll seat with you for a moment
- D. Call me when you feel like talking to me
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
5. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?
- A. Open sterile packages using the flap closest to your body first.
- B. Don sterile gloves before opening the sterile package.
- C. Avoid reaching over the sterile field.
- D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.
Correct answer: C
Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.
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