ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. What are the instructions for a behind-the-ear hearing aid?
- A. Remove before sleeping
- B. Remove before shower
- C. Keep on during all activities
- D. Replace every week
Correct answer: B
Rationale: The correct answer is to remove a behind-the-ear hearing aid before showering to prevent water damage. Choice A is incorrect because it is safe to wear the hearing aid while sleeping as it does not pose a risk of damage. Choice C is incorrect because it is advisable to remove the hearing aid during certain activities to prevent damage or loss. Choice D is incorrect as hearing aids do not need to be replaced weekly unless there is an issue with the device.
2. Which intervention reduces reservoirs of infection in a healthcare setting?
- A. Placing capped needles and syringes in puncture-resistant containers
- B. Keeping bedside table surfaces clean and dry
- C. Changing dressings that become wet or soiled
- D. Placing tissues and soiled dressings in paper bags
Correct answer: A
Rationale: Placing capped needles and syringes in puncture-resistant containers is the correct intervention to reduce infection reservoirs in healthcare settings. This practice helps prevent accidental needle-stick injuries and contains potentially infectious materials properly. Keeping bedside table surfaces clean and dry (choice B) is essential for preventing the spread of infections but does not directly address reducing reservoirs of infection. Changing dressings that become wet or soiled (choice C) is important for wound care but does not specifically target infection reservoirs. Placing tissues and soiled dressings in paper bags (choice D) is a proper waste disposal practice but does not directly reduce reservoirs of infection in a healthcare setting.
3. A nurse is preparing to administer medications to four clients. The nurse should administer medications to which client first?
- A. A client who has pneumonia and a WBC count of 11,500/mm3 prescribed piperacillin
- B. A client who has renal failure and a serum potassium of 5.8 mEq/L prescribed sodium polystyrene sulfonate
- C. A client who is post-coronary artery bypass graft (CABG) prescribed atorvastatin
- D. A client who has anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa
Correct answer: B
Rationale: The correct answer is B. The client with renal failure and high potassium levels requires immediate attention because hyperkalemia can lead to life-threatening cardiac complications. Administering sodium polystyrene sulfonate helps lower the potassium levels. Choice A, the client with pneumonia and a high WBC count, although important, does not present an immediate life-threatening condition. Choice C, the post-CABG client prescribed atorvastatin, and Choice D, the client with anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa, do not require immediate intervention compared to managing hyperkalemia in a client with renal failure.
4. A patient is receiving an opioid analgesic for pain management. What is the most important assessment for the nurse to perform?
- A. Monitor the patient's blood pressure.
- B. Assess the patient's respiratory rate.
- C. Monitor the patient's oxygen saturation.
- D. Assess the patient's heart rate.
Correct answer: B
Rationale: The correct answer is to assess the patient's respiratory rate. When a patient is receiving opioids, it is crucial to monitor their respiratory rate as opioids can depress the respiratory system, leading to respiratory depression and potential respiratory failure. Monitoring blood pressure, oxygen saturation, and heart rate are important assessments as well, but the priority lies in assessing respiratory rate due to the risk of respiratory depression associated with opioid use.
5. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
- A. Hold the cane with your left hand
- B. Move the cane forward 18 inches with each step
- C. When walking, move your left foot forward first
- D. Keep your elbow straight when you hold the cane
Correct answer: C
Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.
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