ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. How can a healthcare provider prevent pressure ulcers in an immobile patient?
- A. Turn the patient every 4 hours.
- B. Provide the patient with a special mattress.
- C. Elevate the patient's legs to reduce pressure.
- D. Limit the patient's movement to reduce friction.
Correct answer: B
Rationale: Providing the immobile patient with a special mattress is an effective way to prevent pressure ulcers. Special mattresses help distribute pressure evenly and reduce the risk of developing pressure ulcers by relieving pressure on sensitive areas. Turning the patient every 4 hours (Choice A) is a standard practice to prevent pressure ulcers but may not be as effective as using a special mattress. Elevating the patient's legs (Choice C) can help with circulation but may not directly prevent pressure ulcers. Limiting the patient's movement (Choice D) can lead to other complications and is not a recommended method for preventing pressure ulcers.
2. 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.
3. A client is experiencing chest pain. Which action should the nurse take first?
- A. Administer aspirin
- B. Provide oxygen
- C. Perform an ECG
- D. Administer nitroglycerin
Correct answer: D
Rationale: Administering nitroglycerin is the priority action when a client is experiencing chest pain as it helps alleviate the pain caused by reduced blood flow to the heart. Oxygen can be beneficial, but nitroglycerin takes precedence in this situation. Aspirin can also be given, but nitroglycerin is the priority. Performing an ECG can provide valuable information but is not the first action to take in this scenario.
4. The nurse notes that a healthcare provider has prescribed a higher than normal dose of medication. What action should the nurse take?
- A. Administer the prescribed dose
- B. Ask another nurse to verify the dose
- C. Administer half of the dose
- D. Contact the healthcare provider to clarify the prescription
Correct answer: D
Rationale: When a healthcare provider prescribes a dose that is higher than normal, it is crucial for the nurse to contact the provider to clarify the prescription. Administering the prescribed dose without clarification can lead to potential harm to the patient due to the elevated dosage. Asking another nurse to verify the dose may not provide the necessary clarification from the prescriber. Administering only half of the prescribed dose without consulting the healthcare provider is not the appropriate action, as the full rationale behind the higher dose needs to be understood before any administration.
5. A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?
- A. Monitor the client's intake and output every 6 hours
- B. Administer furosemide to the client
- C. Check the client's IV infusion every 8 hours
- D. Offer the client 240 ml (8 oz) of oral fluids every 4 hours
Correct answer: D
Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.
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