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 manager is discussing electronic medical records with a newly licensed nurse. Which of the following actions should the nurse take to maintain client confidentiality?
- A. Log out of the computer terminal before leaving.
- B. Share passwords for computer access with colleagues.
- C. Change computer access passwords on a regular basis.
- D. Avoid accessing information about clients admitted to other units.
Correct answer: A
Rationale: The correct answer is A: Log out of the computer terminal before leaving. Logging out before leaving the computer terminal is crucial to ensuring patient data remains confidential and to prevent unauthorized access. Choice B is incorrect because sharing passwords compromises confidentiality. Choice C is incorrect as changing passwords regularly, although a good practice for security, is not directly related to maintaining client confidentiality. Choice D is incorrect as it does not address the immediate concern of maintaining client confidentiality through proper access to electronic medical records.
3. A client has a new prescription for guaifenesin. What information regarding the action of guaifenesin should the nurse include in the teaching?
- A. Decreases mucus production
- B. Reduces nasal congestion
- C. Increases cough production
- D. Reduces fever
Correct answer: C
Rationale: The correct answer is C: 'Increases cough production.' Guaifenesin is an expectorant that works by increasing cough production to help clear secretions from the airways. Option A is incorrect because guaifenesin does not decrease mucus production but rather helps to make the mucus easier to cough up. Option B is incorrect as guaifenesin does not reduce nasal congestion. Option D is incorrect because guaifenesin does not have any effect on reducing fever.
4. Which therapeutic technique is recommended for clients with somatic symptom disorder?
- A. Encourage complete bed rest
- B. Limit the amount of time the client spends discussing symptoms
- C. Monitor the client's food intake
- D. Educate the client on lifestyle changes to reduce symptoms
Correct answer: B
Rationale: The correct therapeutic technique recommended for clients with somatic symptom disorder is to limit the amount of time the client spends discussing symptoms. By doing so, the focus can be shifted away from the illness, helping the client to manage their condition better. Encouraging complete bed rest (Choice A) is not typically recommended as it may reinforce illness behaviors. Monitoring the client's food intake (Choice C) may not directly address the psychological aspects of somatic symptom disorder. Educating the client on lifestyle changes (Choice D) is important but may not be as effective initially as limiting symptom-focused discussions.
5. Which intervention is most effective in preventing deep vein thrombosis (DVT) in a postoperative patient?
- A. Encourage the patient to drink plenty of fluids.
- B. Encourage early ambulation and leg exercises.
- C. Administer anticoagulants as prescribed.
- D. Apply compression stockings to the patient's legs.
Correct answer: B
Rationale: The most effective intervention in preventing deep vein thrombosis (DVT) in a postoperative patient is to encourage early ambulation and leg exercises. Early ambulation helps promote circulation, preventing stasis and reducing the risk of blood clot formation. Encouraging the patient to drink plenty of fluids (choice A) is important for overall health but is not the most effective intervention for preventing DVT. Administering anticoagulants (choice C) is a valuable intervention in some cases, but it may not be suitable for all postoperative patients. Applying compression stockings (choice D) can help prevent DVT but is generally not as effective as early ambulation and leg exercises in postoperative patients.
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