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 goal is most appropriate for a patient who has had a total hip replacement?
- A. The nurse will assist the patient in ambulating in the hall 2 times a day.
 - B. The patient will walk 100 feet using a walker by the time of discharge.
 - C. The patient will ambulate briskly on the treadmill by the time of discharge.
 - D. The patient will ambulate independently by the time of discharge.
 
Correct answer: B
Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.
3. The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
- A. Prepare for potential posttraumatic stress related to this bioterrorism attack.
 - B. Transport patients quickly and efficiently through the elevators.
 - C. Monitor for specific symptoms related to the bioterrorism attack.
 - D. Manage all patients using standard precautions.
 
Correct answer: D
Rationale: During a potential bioterrorism attack, the priority for the nurse is to manage all patients using standard precautions. This approach ensures the safety of both patients and healthcare providers by preventing the spread of potential bioterrorism-related illnesses. Option A is incorrect because managing patient care and safety through standard precautions takes precedence. Option B is incorrect as patient transport should also be done while adhering to infection control measures. Option C is incorrect as monitoring for specific symptoms is important but not the priority when all patients need to be managed with standard precautions.
4. How does a healthcare professional assess a patient's fluid balance, and what signs indicate fluid overload?
- A. Checking lung sounds for crackles
 - B. Checking for signs of orthopnea
 - C. Monitoring intake and output, and checking for edema
 - D. Measuring daily weight
 
Correct answer: C
Rationale: The correct answer is monitoring intake and output and checking for edema. Monitoring intake and output provides information about fluid balance in the body, while checking for edema helps assess for fluid overload. Lung sounds and signs of orthopnea are more indicative of respiratory issues rather than fluid balance. Daily weight measurement is useful to assess fluid status, but it alone may not provide a comprehensive evaluation of fluid balance.
5. A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Suggest that the client use a salt substitute
 - B. Obtain a 12-lead ECG
 - C. Obtain a blood sample for a serum sodium level
 - D. Advise the client to add citrus juices and bananas to their diet
 
Correct answer: B
Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.
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