ATI RN
ATI Capstone Comprehensive Assessment B
1. A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
- A. Determining the need for restraints
- B. Obtaining an order for a restraint
- C. Assessing the patient's orientation
- D. Applying the restraint
Correct answer: D
Rationale: The correct answer is applying the restraint (Choice D). Nursing assistive personnel can be delegated the task of applying restraints under the supervision and direction of a nurse. Determining the need for restraints (Choice A) and obtaining an order for a restraint (Choice B) involve clinical judgment and assessment, which are responsibilities of the nurse. Assessing the patient's orientation (Choice C) also requires a level of assessment that should be performed by a nurse.
2. When considering a bone marrow transplant for a client with leukemia, which ethical principle pertains to minimizing harm to the client?
- A. Justice
- B. Nonmaleficence
- C. Autonomy
- D. Beneficence
Correct answer: B
Rationale: The correct answer is B: Nonmaleficence. Nonmaleficence is the ethical principle that emphasizes the obligation to do no harm, making it crucial in medical decision-making. In the context of a bone marrow transplant for a client with leukemia, the primary concern is to minimize harm and avoid causing any unnecessary suffering or adverse effects. Choices A, C, and D are incorrect: Justice relates to fairness in resource allocation and treatment decisions, Autonomy involves respecting the patient's right to make decisions about their own care, and Beneficence refers to the obligation to act in the patient's best interest and promote their well-being, which may involve some level of risk or harm for overall benefit.
3. A healthcare professional is assessing a client who has a hip fracture. Which of the following findings should the healthcare professional expect?
- A. Hip pallor
- B. Leg abduction
- C. Muscle spasms
- D. Leg lengthening
Correct answer: C
Rationale: Muscle spasms are a common finding in clients with hip fractures. The muscle spasms occur due to the body's natural response to the injury, causing involuntary contractions. Hip pallor (Choice A) is not typically associated with hip fractures. Leg abduction (Choice B) and leg lengthening (Choice D) are not typical findings in clients with hip fractures, as the fracture usually results in limited range of motion and shortening of the affected limb.
4. How should a healthcare professional respond to a patient experiencing hypoglycemia?
- A. Rechecking the blood glucose level in 15 minutes
- B. Encouraging the patient to eat a high-protein snack
- C. Administering 15g of fast-acting carbohydrates
- D. Administering glucagon if the patient is unconscious
Correct answer: C
Rationale: The correct response to a patient experiencing hypoglycemia is to administer 15g of fast-acting carbohydrates. This helps quickly increase the blood glucose levels in the patient, addressing the low blood sugar. Rechecking the blood glucose level in 15 minutes (Choice A) may delay necessary intervention, encouraging a high-protein snack (Choice B) is not recommended as it does not rapidly increase blood sugar levels, and administering glucagon if the patient is unconscious (Choice D) is typically done in severe cases of hypoglycemia when the patient is unable to eat or drink.
5. What are the nursing considerations when caring for a patient with chronic obstructive pulmonary disease (COPD)?
- A. Encouraging pursed-lip breathing to improve ventilation
- B. Administering bronchodilators and corticosteroids
- C. Monitoring oxygen saturation and ABGs
- D. Teaching the patient how to use an inhaler
Correct answer: A
Rationale: The correct answer is A. Pursed-lip breathing is a nursing consideration for patients with COPD as it helps improve oxygenation and reduces air trapping. While administering bronchodilators and corticosteroids (choice B) is part of the treatment plan, it is typically done by healthcare providers. Monitoring oxygen saturation and arterial blood gases (ABGs) (choice C) is important but not a direct nursing consideration. Teaching the patient how to use an inhaler (choice D) is relevant but not specific to COPD care.
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