ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. What are the key considerations when administering medication via a nasogastric (NG) tube?
- A. Checking tube placement before administration
- B. Administering medication in liquid form whenever possible
- C. Crushing tablets and mixing them with water if needed
- D. Flushing the NG tube with water before and after medication
Correct answer: A
Rationale: The correct answer is A: Checking tube placement before administration. This is a crucial step to ensure that the medication reaches the stomach safely and does not end up in the lungs, which can lead to serious complications. Choice B is incorrect as not all medications can be administered in liquid form. Choice C is incorrect because crushing tablets can alter their effectiveness or cause harm. Choice D is incorrect as flushing the NG tube with water is not a standard practice before administering medication, unless specified by healthcare provider instructions.
2. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?
- A. Lock beds and wheelchairs when not in use
- B. Administer a sedative at bedtime
- C. Provide information about home safety checks
- D. Teach balance and strengthening exercises
Correct answer: A
Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.
3. What is the most important nursing intervention when caring for a patient with a wound?
- A. Apply an occlusive dressing over the wound.
- B. Clean the wound with normal saline.
- C. Administer antibiotics as prescribed.
- D. Reassess the wound every 4 hours for changes.
Correct answer: B
Rationale: The most important nursing intervention when caring for a patient with a wound is to clean the wound with normal saline. This is crucial for preventing infection and promoting healing. Applying an occlusive dressing (Choice A) can be important but should come after cleaning the wound. Administering antibiotics (Choice C) is not the first-line intervention for all wounds and should be based on the healthcare provider's prescription. Reassessing the wound (Choice D) is essential but not the most important initial intervention.
4. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements indicates an understanding of the teaching?
- A. I should avoid taking acetaminophen while taking this medication
- B. I will take this medication at the same time each day
- C. I will need to get my blood tested regularly while taking this medication
- D. I should increase my intake of leafy green vegetables
Correct answer: C
Rationale: The correct answer is C. Warfarin therapy requires regular blood testing to monitor INR levels and ensure therapeutic dosing. Option A is incorrect because acetaminophen can be taken with warfarin. Option B is not specific to warfarin administration. Option D is incorrect as it does not address the key monitoring requirement of blood testing while on warfarin.
5. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?
- A. Report any urine output greater than 30 mL/hr.
- B. Bruising on the arms and legs.
- C. Positive Trousseau's sign.
- D. Urine output of 60 mL/hr.
Correct answer: B
Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.
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