ATI RN
ATI Capstone Comprehensive Assessment B
1. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?
- A. Encourage the patient to take deep breaths.
- B. Assist the patient to sit down slowly.
- C. Instruct the patient to use a walker for support.
- D. Teach the patient how to change positions safely.
Correct answer: B
Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.
2. A nurse is caring for a client who had a total thyroidectomy and has a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?
- A. Shortened QT intervals
- B. Hypoactive deep tendon reflexes
- C. Tingling of the extremities
- D. Constipation
Correct answer: C
Rationale: The correct answer is C: Tingling of the extremities. Tingling is a common symptom of hypocalcemia, which is expected with low calcium levels after a thyroidectomy. Option A, shortened QT intervals, is associated with hypercalcemia rather than hypocalcemia. Option B, hypoactive deep tendon reflexes, is not typically related to hypocalcemia. Option D, constipation, is not a common finding associated with low calcium levels.
3. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?
- A. Encourage the patient to perform incentive spirometry.
- B. Assist the patient in ambulating around the unit.
- C. Reposition the patient every 2 hours.
- D. Administer pain medication as prescribed.
Correct answer: A
Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.
4. A healthcare provider is assessing a client who has carpal tunnel syndrome. The provider should expect which of the following findings?
- A. Positive Chvostek's sign
- B. Cool extremities
- C. Positive Phalen's sign
- D. Decreased radial pulse
Correct answer: C
Rationale: Phalen's sign is often positive in clients with carpal tunnel syndrome due to nerve compression. Chvostek's sign (Choice A) is related to hypocalcemia, cool extremities (Choice B) are not typically associated with carpal tunnel syndrome, and decreased radial pulse (Choice D) is not a common finding in carpal tunnel syndrome.
5. A patient with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. What is the most appropriate action to improve the patient's oxygenation?
- A. Encourage the patient to use incentive spirometry.
- B. Administer oxygen via nasal cannula as prescribed.
- C. Assist the patient with coughing and deep breathing exercises.
- D. Position the patient in a high Fowler's position.
Correct answer: B
Rationale: Administering oxygen via nasal cannula as prescribed is the most appropriate action to improve the patient's oxygenation in COPD. Oxygen therapy helps maintain adequate oxygen levels in the blood, which is crucial for managing COPD. Encouraging the use of incentive spirometry, assisting with coughing and deep breathing exercises, and positioning the patient in high Fowler's position are all beneficial interventions, but administering oxygen is the priority for immediate oxygenation support in COPD.
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