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. A patient requires assistance to stand from a sitting position. Which action by the nurse ensures patient safety?
- A. Allow the patient to pull up on the nurse's arm.
- B. Place a gait belt around the patient for support.
- C. Have the patient push off the chair with their hands.
- D. Ask the patient to lift themselves up without support.
Correct answer: B
Rationale: The correct answer is B. Placing a gait belt around the patient for support is the safest option when assisting a patient to stand from a sitting position. This belt provides stability and support, reducing the risk of falls or injuries during the transfer. Choices A, C, and D are incorrect. Allowing the patient to pull up on the nurse's arm (Choice A) may lead to instability and compromise safety. Having the patient push off the chair with their hands (Choice C) might not provide sufficient support, especially for patients who require assistance. Asking the patient to lift themselves up without support (Choice D) can be dangerous and increase the risk of falls.
3. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?
- A. Determining the level of comfort
- B. Changing the patient's position
- C. Identifying immobility hazards
- D. Assessing circulation
Correct answer: B
Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient every 2 hours can be delegated to nursing assistive personnel as it involves physically moving the patient. Tasks like determining the level of comfort (choice A) and assessing circulation (choice D) are clinical judgments that require a nursing license and should be performed by the nurse. Similarly, identifying immobility hazards (choice C) involves critical thinking and assessment skills that are within the nurse's scope of practice.
4. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?
- A. Suction the tracheostomy to maintain a patent airway.
- B. Administer pain medication as prescribed.
- C. Change the tracheostomy dressing every 4 hours.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.
5. The nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for?
- A. Loss of weight
- B. Loss of bone mass
- C. Loss of hope
- D. Loss of strength
Correct answer: C
Rationale: When a patient is immobile, the nurse should assess for psychosocial aspects, including a loss of hope and increased risk of depression. While issues like weight loss (choice A), loss of bone mass (choice B), and loss of strength (choice D) can also occur due to immobility, the primary concern in this scenario is the patient's mental and emotional well-being, making 'Loss of hope' the correct answer.
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