ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A patient with diabetes is admitted with high blood sugar levels. What is the nurse's priority intervention?
- A. Administer insulin as prescribed.
- B. Encourage the patient to exercise regularly.
- C. Encourage the patient to drink water.
- D. Provide the patient with a low-sugar diet.
Correct answer: A
Rationale: Administering insulin is the priority intervention for a patient admitted with high blood sugar levels because it helps lower the blood sugar levels effectively and rapidly. Insulin is a crucial medication for managing hyperglycemia in diabetes. Encouraging exercise (choice B) can be beneficial in the long term for managing blood sugar levels but is not the most immediate priority. While staying hydrated (choice C) is important, it is not the priority intervention when dealing with high blood sugar levels. Providing a low-sugar diet (choice D) is essential for long-term diabetes management but is not the immediate action needed to address high blood sugar levels in an admitted patient.
2. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Inject at a 90-degree angle
- B. Inject at a 45-degree angle
- C. Massage the injection site after administering
- D. Use a longer needle
Correct answer: B
Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.
3. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?
- A. Bend at the waist when picking up objects.
- B. Avoid lying on the operative side.
- C. Avoid lifting more than 10 lb.
- D. Apply ice to the affected eye.
Correct answer: C
Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.
4. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notices clots in the client's urinary catheter and decreased urinary output. Which of the following actions should the nurse take?
- A. Administer an antispasmodic
- B. Irrigate the catheter with 0.9% sodium chloride irrigation
- C. Apply gentle manual pressure to the bladder
- D. Clamp the catheter tubing
Correct answer: B
Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation. This action helps clear the clots in the catheter and restore proper urine flow after a TURP. Administering an antispasmodic (Choice A) is not the appropriate action for clots in the catheter and decreased urinary output. Applying gentle manual pressure to the bladder (Choice C) or clamping the catheter tubing (Choice D) could potentially worsen the situation by causing bladder distention or preventing urine drainage.
5. 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.
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