ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A healthcare provider is planning care for a client who has fluid overload. Which of the following actions should the provider plan to take first?
- A. Assess for edema
- B. Evaluate electrolytes
- C. Restrict fluid intake
- D. Administer diuretics
Correct answer: B
Rationale: Evaluating electrolytes is crucial when addressing fluid overload as it helps determine the severity of the imbalance and guides treatment. Assessing for edema (Choice A) is important but not the priority over evaluating electrolytes. Restricting fluid intake (Choice C) and administering diuretics (Choice D) are interventions that may be necessary but should be based on the electrolyte evaluation to ensure safe and effective care.
2. A healthcare provider is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
- A. Bladder scan shows 525 mL
- B. Absent urinary output for 1 hour
- C. Cloudy urine
- D. Bloody urine
Correct answer: A
Rationale: The correct answer is A. A large bladder scan result (525 mL) suggests catheter blockage and may require irrigation to resolve. Choice B (absent urinary output for 1 hour) could indicate a different issue such as urinary retention but does not specifically indicate the need for catheter irrigation. Choices C (cloudy urine) and D (bloody urine) may suggest infection or other urinary issues, but they do not directly indicate the need for catheter irrigation.
3. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?
- A. Redness and swelling are normal after surgery
- B. Any drainage from the incision site is not concerning
- C. Yellow drainage is normal
- D. I should monitor for increased redness or warmth
Correct answer: B
Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.
4. A client with a urinary tract infection is prescribed ciprofloxacin. Which instruction should the nurse provide?
- A. Continue taking this medication until you feel better
- B. Take this medication with milk or food
- C. Take the medication with an antacid
- D. Avoid caffeine while taking this medication
Correct answer: D
Rationale: The correct instruction for the nurse to provide to a client taking ciprofloxacin for a urinary tract infection is to avoid caffeine. Ciprofloxacin can interact with caffeine, potentially leading to increased side effects or reduced effectiveness. Choice A is incorrect because antibiotics should be taken for the full prescribed course, even if the client starts feeling better. Choice B is incorrect as ciprofloxacin should not be taken with dairy products or antacids as they can interfere with the absorption of the medication.
5. 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.
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