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 client is prescribed 1g of potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g in 250 ml of dextrose 5%. What rate should the nurse set the IV pump to run at?
- A. 40 ml/hr
- B. 42 ml/hr
- C. 44 ml/hr
- D. 46 ml/hr
Correct answer: B
Rationale: To calculate the IV rate, divide the total volume by the total time in hours. In this case, 1 g in 250 ml is to be infused over 6 hours. Therefore, 250 ml / 6 hr = 42 ml/hr. This means the IV pump should be set to run at 42 ml/hr. Choices A, C, and D are incorrect as they do not accurately calculate the infusion rate based on the provided information.
3. A client has urinary incontinence, and the nurse is caring for them. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
- A. Request a prescription for the insertion of an indwelling urinary catheter
- B. Check the client's skin every 8 hours for signs of breakdown
- C. Apply a moisture barrier ointment to the client's skin
- D. Clean the client's skin and perineum with hot water after each episode of incontinence
Correct answer: C
Rationale: The correct action to prevent skin breakdown in a client with urinary incontinence is to apply a moisture barrier ointment to the skin. This ointment helps protect the skin from the harmful effects of moisture exposure, reducing the risk of breakdown. Requesting an indwelling urinary catheter (Choice A) should not be the first-line intervention for skin breakdown prevention. Checking the client's skin for signs of breakdown (Choice B) is important but not as effective as applying a moisture barrier. Cleaning the skin with hot water (Choice D) can actually be detrimental as hot water can strip the skin of its natural oils and worsen skin integrity.
4. A client has a new prescription for lisinopril. Which of the following statements indicates an understanding of the teaching?
- A. I should take this medication with food
- B. I should report a cough to my provider
- C. I should expect to have facial swelling when taking this medication
- D. I should increase my intake of potassium-rich foods
Correct answer: B
Rationale: The correct answer is B. Reporting a cough is crucial when taking lisinopril as it can be a sign of a serious side effect, such as angioedema or cough associated with ACE inhibitors. Option A is incorrect because lisinopril can be taken with or without food. Option C is incorrect as facial swelling is not an expected side effect of lisinopril. Option D is incorrect because lisinopril can cause hyperkalemia, so increasing potassium-rich foods without healthcare provider guidance can be dangerous.
5. A patient with a history of hypertension is admitted for chest pain. What is the most appropriate action for the nurse to take first?
- A. Obtain a detailed medical history
- B. Administer nitroglycerin
- C. Conduct an ECG
- D. Administer morphine sulfate
Correct answer: B
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient presenting with chest pain as it helps dilate blood vessels, reduce chest pain, and improve oxygen supply to the heart. Obtaining a detailed medical history, conducting an ECG, or administering morphine sulfate are important steps in the assessment and treatment process but are secondary to the immediate need to address chest pain and potential cardiac ischemia.
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