ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A client who has been having frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse add to the client's plan of care?
- A. Apply restraints
- B. Use soft wristbands
- C. Wrap blankets around side rails
- D. Administer sedatives
Correct answer: C
Rationale: The correct action the nurse should add to the client's plan of care is to wrap blankets around side rails. This helps prevent injury during seizures by providing a cushioned surface against the hard rails. Applying restraints (Choice A) is not recommended as it can cause harm during a seizure. Using soft wristbands (Choice B) may not provide adequate protection against injury. Administering sedatives (Choice D) is not typically indicated for managing tonic-clonic seizures as they require specific anti-seizure medications.
2. Retention of electrolytes (especially sodium) in the interstitial fluid can result from:
- A. decreased aldosterone secretion.
- B. increased ADH secretion.
- C. increased aldosterone secretion.
- D. decreased ADH secretion.
Correct answer: C
Rationale: The correct answer is C: increased aldosterone secretion. Aldosterone, a hormone produced by the adrenal glands, increases sodium reabsorption in the kidneys, leading to retention of sodium and water in the interstitial fluid. Increased aldosterone secretion enhances the reabsorption of sodium, thereby increasing its retention. Choice A is incorrect because decreased aldosterone secretion would lead to less sodium reabsorption and increased excretion. Choice B is incorrect because increased ADH secretion primarily affects water reabsorption rather than sodium. Choice D is incorrect because decreased ADH secretion would lead to increased water excretion but not necessarily affect sodium retention.
3. A nurse is providing discharge teaching to a client who has a wound infection. Which of the following information should the nurse include about home care?
- A. Soak the wound in warm water every day
- B. Use hydrogen peroxide to clean the wound
- C. Apply a cold compress to the wound
- D. Keep the wound covered with a dry dressing
Correct answer: D
Rationale: The correct answer is D: 'Keep the wound covered with a dry dressing.' When providing care for a wound infection, it is essential to keep the wound covered with a dry dressing to prevent further contamination and promote healing. Soaking the wound in warm water (choice A) can introduce moisture and increase the risk of infection. Using hydrogen peroxide (choice B) can be too harsh and may slow down the healing process by damaging healthy tissue. Applying a cold compress (choice C) is not typically recommended for wound infections, as it may not provide the necessary environment for healing.
4. According to the principles of standard precautions, when should gloves be worn by healthcare providers?
- A. Providing a back massage
- B. Feeding a client
- C. Providing hair care
- D. Providing oral hygiene
Correct answer: D
Rationale: Gloves should be worn when providing oral hygiene as it involves potential exposure to bodily fluids, aligning with the standard precautions to prevent the transmission of infections. Providing a back massage, feeding a client, and providing hair care do not typically involve direct exposure to bodily fluids, so wearing gloves is not necessary in these scenarios according to standard precautions.
5. Which of the following theories explains that organizations are made up of intertwined links and diversified choices that generate unanticipated consequences?
- A. Contingency theory
- B. Closed system theory
- C. Open system theory
- D. Chaos theory
Correct answer: D
Rationale: The chaos theory explains that organizations are made up of intertwined links and diversified choices that generate unanticipated consequences. Choice A, Contingency theory, focuses on how organizations adapt to their environment. Choice B, Closed system theory, suggests that organizations are self-contained and do not interact with their environment. Choice C, Open system theory, emphasizes that organizations interact with their environment but does not specifically address intertwined links and diversified choices generating unanticipated consequences.
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