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. Which nursing action will best promote patient safety when administering medications?
- A. Check the patient's wristband before administering medications.
- B. Confirm the patient's allergies prior to administration.
- C. Document the medications immediately after administration.
- D. Prepare medications at the medication cart to minimize distractions.
Correct answer: B
Rationale: Confirming the patient's allergies before administering medications is crucial for patient safety as it helps prevent adverse reactions. Checking the patient's wristband is important for identification but may not directly impact medication safety. Documenting medications after administration is necessary but does not primarily promote safety during administration. Preparing medications at the medication cart, rather than the nurse's station, is preferred to ensure accuracy and proper medication handling, but it is not directly related to confirming allergies for safety.
3. How should a healthcare provider manage a patient with deep vein thrombosis (DVT)?
- A. Monitoring for signs of pulmonary embolism
- B. Applying compression stockings
- C. Administering anticoagulants as prescribed
- D. Encouraging leg elevation to reduce swelling
Correct answer: A
Rationale: Corrected Rationale: Monitoring for signs of pulmonary embolism is crucial in patients with deep vein thrombosis (DVT) as it can be a life-threatening complication. While administering anticoagulants as prescribed is important for preventing clot progression, the immediate concern is detecting potential pulmonary embolism. Applying compression stockings and encouraging leg elevation are beneficial measures for managing DVT symptoms but are not as critical as monitoring for pulmonary embolism.
4. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?
- A. Loud volume of the television set
- B. Wall-to-wall carpet in the living room
- C. Low chairs without armrests
- D. Use of indirect lighting
Correct answer: C
Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.
5. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?
- A. Encourage visitors during visiting hours.
- B. Keep the patient on fall precautions until discharge.
- C. Check on the patient every shift.
- D. Raise all four side rails.
Correct answer: B
Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.
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